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Officers

Kenneth L. Reed, DMDPresident

Michael Rollert, DDSPresident Elect

Daniel S. Sarasin, DDSVice President

Morton B. Rosenberg, DMDTreasurer

Clyde E. Waggoner, DMDSpeaker of the House

Ronald Kosinski, DMDImmediate Past President

Board of Directors

Edward C. Adlesic, DMDDirector

David L. Rothman, DDSDirector

Paul J. Schwartz, DMDDirector

Paul Sims DDSDirector

Roy L. Stevens, DDSDirector

Ex OfficioSteven I. Ganzberg, DMDEditor In Chief: Anesthesia Progress

Roy L. Stevens, DDSEditor in Chief

Submission GuidelinesPulse welcomes submission of items of interest to society members. Items including let-ters to the editor, referenced scientific articles, case reviews, point-counter point opinion articles, component, legislative and residency news, along with book and product reviews will be considered for publication. All submissions must contain the name, professional degree(s), and contact information of the author(s). Scientific articles, case reviews and point-counter point articles must also contain a photograph of the author. Pulse is published quarterly by the American Dental Society of Anesthesiology. Items can be submitted elec-tronically to Knight Charlton, ADSA Executive Director at: [email protected] and Dr. Roy L. Stevens, Editor at [email protected].

In addition to patient safety, which is a theme throughout all issues of The Pulse, this issue will focus on pediatrics. Unfortunately, dentists continue to have adverse outcomes when we treat pediatric patients whether it is with local anesthesia alone, oral sedation or deep sedation and general anesthesia. This may be due to a lack of training, lack of experience treating pediatric patients, not truly understanding the differences between adult and pediatric patients – not just anatomical and physiological but also psychological, or other reasons. It is a problem that, as a profession, we need to recognize and formulate a plan of action to confront. In 2014, a pediatric textbook (Behavior Management in Dentistry for Children. Second Edition. Editors: Wright, GZ., Kupietzky, A. Wiley. April, 2014) was updated. In that text there is a discussion of local anesthesia overdose:

“Many dentists will not recognize a local anesthetic overdose until a seizure is seen. Of course, prevention is primary. Do not exceed the manufacturer’s maximum recommended doses for the local anesthetics chosen and this problem will essentially cease to exist. Local anesthetic overdoses are only fatal if the patient’s airway is not maintained throughout the episode. Head tilt with chin lift and/or jaw thrust is essential.“1

It really is pretty simple.

Additionally, 15 years ago Charles Coté published a series of three articles discussing adverse sedation events in pediatrics. Unfortunately, dentistry was well represented. In one of those articles he discussed the medications used when these adverse events occurred:

Negative outcomes (death and permanent neurologic injury) were often associated with drug overdose. The use of three or more sedating medications compared with one or two medications was strongly associated with adverse outcomes. Deaths and injuries after discharge from medical supervision were associated with the use of medications with long half-lives (chloral hydrate, pentobarbital, promazine, promethazine, and chlorpromazine).2

Also, I’ll relate a few thoughts from Leslie Hall, a physician anesthesiologist:

“When discussing the use of ‘minimal’ sedation or ‘conscious’ sedation in children, I like to tell sedation providers to think about sedation in terms of consent. In adults, we get consent prior to sedation - for children, we sedate in order to get their consent (I’m not talking about parental consent here). How much sedation does it take to make someone consent to something that they don’t agree with, don’t want or haven’t bought into? Ask yourself the same question - if you said no to a procedure, how much sedation would it take to make you say yes. Most of us would say, ‘Over my dead body’ or ‘You’d have to knock me out completely’.”2

Dr. Hall expresses very well the challenges we have in trying to sedate a child. It is very, very different than sedating an adult and not understanding all of these differences may lead to adverse occurrences.

1. Behavior Management in Dentistry for Children. Second Edition. Editors: Wright, GZ., Kupietzky, A. Wiley. April, 2014.

2. Coté CJ, Karl HW, Notterman DA, Weinberg JA, McCloskey C. Adverse sedation events in pediatrics: analysis of medications used for sedation. Pediatrics. 2000 Oct;106(4):633-44.

Pediatric Safety

1

Herbert Hoover, 31st President of the United States, insightfully called children “our greatest natural resource”. Indeed, children give our lives meaning, give us hope for the future, and are worthy of protection.

That protection includes providing access to adequate health care. For most of us reading this editorial, it specifically includes access to adequate oral health care.

U.S. Census 2010 revealed there are approximately 48 million children living in the United States under the age of 12 years. With dental caries being the most common chronic disease of childhood, and less than 7,000 residency trained pediatric dentists in practice, it is imperative that general dental practitioners to be involved in providing care of many of these young patients.

Many general practitioners have the desire, knowledge and skill set to treat many of these children and can do so with local anesthesia alone or with the addition of nitrous oxide/oxygen minimal sedation. However, many of these children are unable to tolerate needed dental treatment without some form of sedation beyond nitrous oxide. Some even require general anesthesia. Herein lies the problem.

U.S dental schools do not teach sedation of children to competency, and there are insufficient numbers of residency trained pediatric dentists to meet the need. General

practitioners wishing to provide sedation care for children are left to learn sedation of children through the small hand full of pediatric hospital-based general practice residencies that teach sedation of children to competency. While some dentists have reported to be self taught from internet sources, there are no continuing education courses known to this writer that include clinical hands-on training in the sedation of children and as such, cannot be considered competency courses.

Unfortunately, the absence of teaching guidelines for minimal and moderate sedation of children 12 years and under in the ADA Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students and in the CODA accreditation standards for general practice residencies has resulted in wide variation in the few pediatric hospital-based GPR programs available for general practitioners. The AAP/AAPD Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures , to which the ADA guidelines defer for management of children 12 years and under, also lack training guidelines for non-pediatric dentists. The lack of teaching guidelines also gives state regulatory bodies little guidance in formulating regulations that protects children during sedation in dental offices. As a result, the few states that require a permit for the sedation of

2

Protecting Our Greatest Natural Resource

children have training requirements that vary from one requiring a simple 16 hour lecture course with no clinical experiences to one requiring a 60 hour/20 clinical case course in adult parenteral sedation. Most states have no pediatric specific sedation regulations.

It was encouraging to read the Background and Consideration of Comments sections of Resolution 77 (proposed amendments to the sedation and anesthesia guidelines), recently presented to the 2015 ADA House of Delegates by the Council on Dental Education and Licensure (CDEL), which reported the suggestion by the American Academy of Pediatric Dentistry (AAPD), American Academy of Pediatrics (AAP) and American Dental Society of Anesthesiology (ADSA) that new guidelines focused on the provision of sedation and anesthesia to children age 12 and under by dentists who are not pediatric dentists or dentist anesthesiologists by education and training be developed. CDEL intends to study the issue in 2016.

Guidelines, specifically teaching guidelines for minimal and moderate sedation of children for dentists not specialty trained in pediatric dentistry or dental anesthesiology are long overdue and necessary for patient safety as well as improving access for children requiring sedation care.

Access to care for children who are not candidates for minimal or moderate sedation, but rather require general anesthesia to ensure their cooperation and safety, is also a

3

In This Issue

1 | President’s Message

2 | Editorial

5 | Future ADSA Meetings

6 | Sedation and Medical Emergencies in the Pediatric Patient

14 | Pediatric Sedation Review Course - Las Vegas

16 | Opioid Prescribing in the Pediatric Population

17 | Rollert Pediatric Emergency Drug Calculator

18 | News Briefs

20 | Abstracts

22 | IFDAS Berlin

continued

4

concern. Anecdotal reports of hospitals and outpatient surgery centers in some parts of the country limiting pediatric dental cases, even for pediatric dentists, are becoming more frequent. A few are also reported to not renewing general practitioner or pediatric dentist’s credentials to practice in their facilities. Complicating matters further, some state dental boards have passed regulations that essentially forbid or severely limit mobile anesthesia care in dental offices provided by dentist anesthesiologists with 2 to 3 years of CODA-accredited general anesthesia training. On the other hand, in a misguided attempt to improve access, at least one state, that requires certified registered nurse anesthetists to work only under medical supervision in a hospital, surgery center or office, allows dentists without any formal anesthesia training to provide that “supervision” of the nurse’s anesthetic. Common sense would dictate a dentist with no formal anesthesia training cannot anymore safely supervise a nurse anesthetist providing general anesthesia than the nurse anesthetist could safely supervise the dentist placing stainless steel crowns.

While some barriers to general anesthesia care are due to economic considerations, some have been self-inflicted by organized dentistry with the unintended consequences of limiting access to care for children and endangering their safety. If we can all agree that access to safe pediatric dental care under general anesthesia is paramount, then there is no place for the anesthesia turf wars involving adult patient care that have resulted in stifling access to safe

anesthesia care for children and those with special needs. Our profession must come together regarding the variety of acceptable anesthesia and sedation practice philosophies if we are to improve access to care and ensure protection of our nation’s children.

Consistent throughout these challenges to providing safe and effective anesthesia and sedation care for children is ADSA’s ongoing commitment to providing quality continuing education for all dentists with interest in pain and anxiety control. In addition to review and emergency simulation courses for moderate sedation providers, deep sedation/general anesthesia providers and dental assistant team members, our society also offers a review course in Las Vegas in March 2016 for those dentists caring for and sedating children.

This edition of Pulse is dedicated to those providing sedation and anesthesia based dental care for our nation’s children. It is hoped that all of our profession can lay aside past differences to openly discuss how we can work together to safely improve access to care for our country’s greatest natural resource.

Best Regards,

Roy L. Stevens, D.D.S.Editor

Protecting Our Greatest Natural Resource

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UP TO DATE INFO ONLINE AT: www.adsahome.org

ADSA www.adsahome.org

GENERAL ANESTHESIA

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Sedation and Medical Emergencies in the Pediatric Patientby David L. Rothman, D.D.S.

Two categories of pediatric emergency

can occur during sedation. Anesthesia

associated problems usually are airway

related and lead to hypoxia and cascade

to bradycardia and potentially death.

Examples of these include drug/dose

problems, unintended sedation level

changes, allergic reactions to the agents

used, laryngospasm and loss of protective

reflexes. Non-anesthesia emergencies can

occur at anytime and are not related to

the sedative or anesthetic agents. These

may occur concurrently or separately and

can include airway obstruction, allergic

reactions, seizures and hypoglycemia. It

is important for the practitioner to be

able to identify and intervene early in the

event to be able to manage the emergency

and stabilize the patient before further

progression.

Though there are many reported numbers

for the incidence of emergencies during

sedation and anesthesia, they may be

unreliable.1, 2, 3 There is no central

reporting agency in dentistry for incidences

of morbidity or simple complications

which don’t affect the outcome of the

sedation. Mortality numbers are difficult

to obtain other than in insurance company

closed case analyses and there exists only

estimates of the number of outpatient

sedations given in a specific time period.

In addition, some practitioners do not

recognize problems or may choose to ignore

them because they believe they are too

minor to record such as temporary loss of

protective reflexes

as the patient drifts

between sedation

levels. Practices

are inconsistent in

their delivery and

monitoring making

data recovery

difficult.

In general, the pediatric heart and lungs

are generally free of disease unless it

is congenital. The second most common

disease affecting children is asthma and

is the most common cause of admission

for the pediatric patient. It affects

approximately 11-15% of children and

is now considered a lifelong disease. It

is important to understand the severity

of the asthma pre and post treatment

and the medications used because of the

impact they may have on the emergency

treatment. Acquired infections of the

airway in children require a 6 week

healing period before sedation or general

anesthesia should be done. Understanding

allergic versus infectious etiology is key

to treatment and prevention of medical

emergencies.

This article is by no means a complete

discourse on pediatric emergency

management and will only focus on

respiratory, cardiovascular, and sedative

and local anesthetic drug overdose

related emergencies. Other pediatric

emergencies will be covered in a future

article. The reader is well advised to do

David L. Rothman, D.D.S.

7

additional research on pediatric diseases

and emergency management of patients

and take appropriate continuing education

courses. Topics such as foreign body

obstruction and complications of the routes

of administration are covered in courses

such as Pediatric Advanced Life Support

by the American Heart Association and the

American Academy of Pediatrics.

Response to EmergenciesThe concept of “rescue”, as proposed

by Cote2 states that the purpose of all

emergency treatment is to manage and

stabilize the patient until help arrives.

Using local emergency services alone

and waiting for their response is not

adequate rescue. Know and understand

if the emergency responders are EMTs

or Paramedics. The office must have the

resources and training necessary to perform

rescue from unintended sedation level

changes, i.e. overdose, as well as other

categories of emergencies. The chances

for a successful outcome decrease with

the distance and time from an emergency

facility.2,5

Learning to rescue alone is not adequate

emergency preparation. Prevention

of the emergency through guidelines,

understanding drug dosages and

pharmacology, with potential interactions,

and knowing your patient and his or her

medical history will mediate the risks

involved. Documenting sedation incidents

in the office and reviewing those with staff

and other practitioners allow us to learn

from experience and modify our delivery,

monitoring and especially our response, be

it as simple as a using a neck and shoulder

roll or one more involved such as drug dose

change. It is recommended that during

sedations, children are maintained at the

minimal or moderate level4 to maintain

their protective reflexes and their airways

patent.

By following guidelines, we are able to

minimize but not totally eliminate risk.

NPO guidelines may leave our patients

at risk for hypovolemia especially if they

perspire profusely while in a medical

immobilization device. The triad of

hypovolemia, hypoxia and hypercarbia

lowers seizure threshold, increases

myocardial irritability and may hinder or

prevent resuscitation efforts. In addition,

certain sedation medications such as chloral

hydrate may increase myocardial irritability

and may negate the use of epinephrine

during emergency care.

Emergency KitThe emergency kit for pediatric patients

must be adequate to maintain a patent

airway and stabilize the child at the level

of sedation achieved as well as treat

any concurrent emergencies until either

help arrives or the patient emerges and

recovers. This implies that if the patient

drops to a level deeper than anticipated,

the doctor must be able to monitor and

maintain the patient at the unintended

level and have the training, equipment and

staff to do so. The emergency kit must also


8


contain equipment and supplies to respond

to other basic pediatric office emergencies

and first aid. An appropriate list is available

in the AAP/AAPD Guidelines for Monitoring

and Management of Pediatric Patients

During and After Sedation for Diagnostic

and Therapeutic Procedures4 (chart 1). The

kit must contain specific equipment and

sizes for pediatric resuscitation including

face masks, advanced airway devices and

equipment for IV and IO access. The kit

must be placed in an identified and easily

reached area and the components must be

clearly marked and labeled. Response must

be organized and practiced with individual

roles assigned to each member of the

response team (chart 2).

Oxygen is always the first drug of choice.

Room air has 21% oxygen content. Oxygen,

as a supplement in emergency situations,

should be delivered at 100% with the

assistance of an appropriately sized

pediatric self-inflating bag valve mask

system. A mobile E-sized tank is capable of

delivering 10 liters/minute of oxygen for

60 minutes and may be used in areas not

plumbed with oxygen. Alternative oxygen

delivery methods may be available but

must meet the requirements of access and

transportability. Without modification,

the standard N2O/O2 delivery unit is not

capable of delivering positive pressure

oxygen because of an overload pop-

off valve in the system. The standard

reservoir bag does not substitute for a

self-inflating bag valve mask though the

unit may be used to supply oxygen to the

BVM.

Masks used in resuscitation should be

transparent with a form fitting inflatable

collar which should also be checked on

a regular basis. A variety of different

sizes should be available and should fit

comfortably between the nasal bridge and

the chin. A 5cc syringe without needle

should be kept with the masks to deflate

or inflate the collar.

Advanced airway devices for managing

airways during emergencies include

nasal and oral airways, endotracheal

tubes (ETT) and appropriate placement

equipment. A valuable adjunct for airway

management is the laryngeal mask

airway (LMA) which may substitute for

intubation in compromised airways. It is

recommended that experience be gained

in this technique. The inflatable collar

may block regurgitated stomach contents

from entering the airway. Various sizes

for pediatric patients must be available.

Correct size oral airways are measured

externally from the tragus to the

commissure of the lips. Nasal airways are

measured externally from the tragus to the

corner of the nares.

Automated Electronic Defibrillators (AED)

are a conundrum in pediatric emergency

care but states are increasingly mandating

their presence in dental offices. Short of

aiding the staff in resuscitating the doctor,

they have little purpose in pediatric

practices as a first line resuscitation

9

device. Most cardiac problems are not

due to disease or congenital issues but

instead to hypoxia leading to a transient

tachycardia with the child succumbing

to a fatal bradycardia. Performing

defibrillation on a hypoxic heart will not

revive it nor correct an arrhythmia.

Routes of Administration of Emergency DrugsIt is recognized that the optimum route

of administration of all emergency

medications is intravascularly or

intraosseously,4,5 although alternate

means are available. Submucosal delivery

in the area distal and superior to the

maxillary molar in the region of the

pterygoid plexus or intramuscularly

into the nearest exposed muscle mass

(gluteal or deltoid) may be used when

there is optimum circulation. Because the

dental practitioner is most comfortable

in the oral cavity, the submucosal site

mentioned is recommended for drugs

that may be given intramuscularly due

to the high vascularity of the area. This

also avoids the possibility of swelling

and airway obstruction if administered

in the floor of the mouth or the tongue.

Diazepam, because of its ethylene glycol

base, is not appropriate for intramuscular

or submucosal administration except in

extreme cases.

Paradigm of Emergency CareThe paradigm of emergency care should

involve a system or method of treatment

that guides our thoughts and actions.

Prior to the 2012 revision of the American

Heart Association’s Pediatric Advanced

Life Support (PALS) course, the mnemonic

of PABCD where P is position, A is airway,

B is breathing, C is circulation, and D is

drugs was used. As with the concept of

rescue, the absence of prevention in the

thought process leads us to a situation

which may be preventable. Therefore, a

paradigm of PPABCD, where the first P is

prevention, PABC are the same, and the D

is definitive treatment (realizing not all

emergencies require drug intervention)

can be considered. The mnemonic has

been recently revised again to stress the

increased focus on circulation. The key

to success is not to progress to the next

letter if the prior letter is not stabilized

i.e. do not attempt breathing if the airway

is not stabilized.

Emergencies of the Respiratory System The most common emergency during

pediatric sedations is hypoxia. It may

be caused by airway obstruction, drug

overdose, local anesthesia overdose or

unintended sedation level, all of which

may lead to reduced respiratory rate and

volume. When respiratory and/or cardiac

rates reach 2/3 of pretreatment rates,

good quality CPR should begin including

bag valve mask (BVM) intervention.

Survival rates after hypoxia and cardiac

arrest are 3-17%6 therefore, early

recognition and management are crucial.

The early signs of hypoxia are restlessness

and agitation, transient increase in heart


rate then decrease, and irregular breathing patterns. The various sounds of respiratory problems may be summarized as follows:

Gurgling fluid or foreign body in the upper airway

Snoring tongue/soft palate/ tonsil obstruction

Crowing large tongue, vocal cord paralysis or swelling, croup, epiglottitis, foreign body, allergic reaction with edema, laryngospasm

Wheezing bronchospasm or partial obstruction of the lower airway on expiration

The treatment of hypoxia, regardless of cause, is as follows:

P (Prevention) Neck roll.

Loose medical immobilization device.

Know sedation level and drug interactions.

Rubber dam carefully placed on single side-not cross arch.

Suction readily available.

P (Position) Supine with head tilt.

Monitor and assess airway and breathing.

A (Airway) Assess patency.

Position tongue forward- no blind sweeps.

Place appropriately sized nasal airway measured from

OPA: tragus to corner of the mouth.

100% O2 by nasal or full face mask.

LMA or intubate if airway does not open.

Monitor and reassess.

B (Breathing) Assess respirations.

Self vs. assisted.

Adequate volume and speed.

Assist as necessary with positive pressure 100% O2 by Bag Valve Mask (BVM).


C (Circulation) Assess perfusion by peripheral/carotid pulses.

Begin CPR.


D (Definitive) Determine cause and treat with appropriate drug.

Activate 911 and transport to emergency facility.

Asthma is the most common cause for admission to hospitals in the pediatric population. Bronchospasm, the end result of asthma, may also be caused by allergies, reactive airway disease following infection or pneumonia, and mechanical or chemical irritation. The most common signs are congestion, wheezing, dyspnea, confusion or agitation and tachypnea and tachycardia. Because the pediatric patient has limited oxygen reserves, intervention must be immediate. The heart will tire quickly and hypoxia, hypovolemia and hypercarbia will ensue quickly with lactic acidosis leading to an irreversible condition.

The treatment of bronchospasm is as follows:

P (Prevention) History

Chromalin/steroid/puffer handy

Decrease anxiety/ supplement with O2

Avoid narcotics (histamine releasers)

P (Position) Partially reclining

A (Airway) 2-4 puffs of albuterol inhaler q 2 minutes for 2 doses

B (Breathing) Assist as necessary

Bag/valve/mask if needed

Prepare to intubate

C (Circulation) Monitor and CPR as needed

D (Definitive) If bronchospasm resolves, continue treatment

If fails to resolve, notify EMS

Laryngospasm may be caused by aspiration of a

foreign body, depth of sedation with partial loss

of protective reflexes or post viral syndrome

with reactive airway disease.

With time, the situation progresses and is harder

to reverse without drug intervention. The

treatment of laryngospasm is as follows:


Respiratory Problems

Hypoxia

Bronchospasm

10

P (Prevention) History of infection

Use of rubber dam and high capacity suction

P (Position) Supine with head tilt and shoulder roll

A (Airway) Check for foreign body/vomitus

Place appropriate length oral airway

B (Breathing) 100% O2 through BVM

Constant mild to moderate pressure- not burst

Drugs prn

Succinylcholine 2-4mg IM with atropine .04mg

Be prepared to ventilate for up to 30 min.

C (Circulation) Monitor for peripheral pulses

CPR prn

D (Definitive) EMS activation and transport

Abnormal Cardiac Rhythm and PulsesArrythmias and dysrythmias may have many causes but the most common include an undiagnosed congenital defect, hypoxia, effects of circulating catecholamines on a sensitized myocardium, drug effects and vagal stimulation. The end result of the arrhythmia is poor perfusion, lowered blood pressure, and the shunting of blood from the peripheral circulation to maintain perfusion of the blood rich group. The Pediatric Advanced Life Support Course (PALS) provides excellent training in the management of this problem. Because arrythmias have the potential to become fatal, rapid identification and treatment are imperative.

P (Prevention) Know patient

Know drug, its interactions and its effects

P (Position) Supine with neck and shoulder roll

A (Airway) Maintain patency

Nasal or oral airway as needed

100 % O2

B (Breathing) Monitor and assist as needed with bag valve mask

Begin CPR if needed

C (Circulation) Monitor and assist as needed

Begin CPR if needed

D (Definitive) Notify EMS and prepare for transport

Sedation Drug OverdoseDespite the practitioner’s best efforts in predicting patient response to a dose of sedative medication, there is always the chance of hyper or hypo reactions to the drug such that the patient slips into a deeper level of sedation than intended. The practitioner must be prepared to respond appropriately and maintain and protect the airway if loss of protective reflexes occurs.

The response to sedation drug overdose is as follows:

P (Prevention) Know drug dose, interactions and effect

Know drug metabolism and half life

Identify levels of sedation and responsiveness

P (Position) Supine with neck and shoulder roll

A (Airway) 100% O2

Oral airway or intubate if needed to guarantee patency

Monitor and reassess

B (Breathing) Assist with BVM as needed

Monitor and reassess

C (Circulation) Monitor and assist with CPR if necessary

D (Definitive) STOP dental procedure

Start IV (required for deep sedation or GA)

Monitor appropriate vital signs

Reversal agents if appropriate

Naloxone 0.01 mg/kg IM q5m to max 1mg.

Flumazenil 0.2mg IV q1m to max 1 mg.

Monitor and assess level of sedation

Local Anesthesia OverdoseThe administration of local anesthesia concurrently with sedative medications constitutes polypharmacy and requires additional caution because of the risk of potentiation and fatal arrythmias secondary to lidocaine or epinephrine overdose. Because its presence decreases the rate of anesthetic absorption, there is no reason for not using local anesthetic with vasoconstrictor during sedation of ASA 1 or 2 patients. In the case of


Laryngospasm

Arrythmias

Sedation Drug Overdose

11

overdose, increasing CNS depression leads to the paradox of increasing CNS stimulation, agitation and talkativeness. The patient exhibits seizures until the blood level falls. Management of this emergency involves stabilizing the patient and monitoring until blood levels fall.

P (Prevention) Follow current local anesthesia guidelines and doses not exceeding 4mg/kg for commercially available drugs

Stop procedure

P (Position) Supine in the unresponsive, sedated patient

Neck and shoulder roll

A (Airway) Usually adequately maintained

Follow precautions for hypoxia

B (Breathing) Usually maintained

100% O2 to prevent hypoxia, hypercarbia\ and acidosis

May be depressed or absent

100% O2 with bag valve mask

C (Circulation) Usually adequately maintained

Hypotension and tachycardia require BLS intervention

D (Definitive) EMS activation and transport

Conclusion

The successful treatment outcome of an in-office emergency of a pediatric patient during sedation is dependent upon rapid identification of a problem and immediate intervention. The emergency situation always takes precedence over the dental procedure. Using recommended monitors and monitoring techniques, early identification of critical events is possible. The practitioner is advised to always be suspicious of changes in the child’s responses. With a well-trained doctor and office staff, practiced in emergency response, the likelihood of mortality or severe disability decreases for the child. Continuous training for all staff members is recommended.

Chart 1Emergency Medications and Equipment 1. oxygen;2. ammonia spirits;3. glucose (50%);4. atropine;5. diazepam;6. epinephrine;7. lidocaine (cardiac);8. diphenhydramine hydrochloride;9. hydrocortisone;10. pharmacologic antagonists (as appropriate) naloxone hydrochloride flumazenil.

Airway management equipment1. nasal and oral airways and clear masks of assorted pediatric and adult sizes;2. portable oxygen delivery system capable of delivering bag and mask ventilation greater than 90% at 10 L/min flow for at least 60 minutes (e.g. “E” cylinder);3. self-inflating breathing bag and reservoir with masks that will accommodate children and adults of all sizes.4. Deep sedation and general anesthesia: assorted pediatric endotracheal tubes, laryngoscopes with straight and curved blades, Magill forceps

Intravenous equipment for deep sedation and general anesthesia1. gloves, 2. alcohol wipes,3. tourniquets,4. sterile gauze pads,5. tape;6. intravenous solutions and equipment for administration appropriate to the patient population being treated a.intravenous catheters (22, 24 gauge) b.intravenous administration set (tubing) (microdrip 60 drops/mL) c.intravenous fluids d.assorted needles for drug aspiration and administration e.appropriately sized syringes


Local Anesthesia Overdose

12

Chart 2Team member 1 - Initiates emergency care

Treat patient/ Basic Life Support

Activates office emergency protocol

- Remains with patient

Team member 2

- Brings supplies/emergency kit medications/02 tank

- Assists 1

Team member 3

- Crowd control

- Notifies emergency backup service on instructions from 1

- Meets EMS and escorts in

- Maintains records

- Assists as needed

References

1. Moore PA. Adverse drug reactions in dental practice: Interactions associated with local anesthetics, sedatives, and anxiolytics. J Am Dent Assoc 1999;130(4):541-4. Domino, D. Are pediatric sedation deaths on the rise? 2010 May 18. 304662.drbicuspid.com

2. Cote CJ, Notterman DA, Karl HW, Weinberg JA, McCloskey C. Adverse sedation events in pediatrics: a critical incident analysis of contributing factors. Pediatrics 2000;105;805.

3. Guidelines for the use of sedation and general anesthesia by dentists (2012). American Dental Association. www.ada.org/ sections/about/pdfs/anesthesia_guidelines.pdf

4. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures (2006) . AAPD Reference Manual 2015, 37(6):211-227

5. American Heart Association. Pediatric Advanced Life Support (2010), course and manual. www.heart.org/PALS

6. Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Circulation 2010, 3 (1): 63–81


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Pediatric Sedation Review CourseLas Vegas 2016

The ADSA Pediatric Sedation Review Course in Las Vegas is a two day course reviewing topics related to the safe and effective sedation of children. It is specifically designed for both pediatric dentists as well as non-pediatric dentists who sedate children during dental procedures.

The course reviews the unique anatomical and physiological aspects of pediatric patients of concern during procedural sedation as well as the pharmacological aspects of the various agents used in this population. Alternative methods of patient management will be reviewed as well as a thorough discussion of patient monitoring necessary during sedation procedures.

The course will feature a thorough discussion of sedative techniques for special populations of children including those with developmental disabilities and medical challenges. The course will conclude with a thorough discussion of management of emergencies seen during procedural sedation of children.

Friday, March 4, 2016

8:00 Introduction Dr. David Rothman - Chair

8:15 Definition of a Pediatric Patient Dr. David Rothman

9:15 Physiology Dr. David Rothman

10:15 Break

10:30 Nitrous Oxide Dr. Robert Bosack

11:00 Local Anesthesia Dr. Joseph Giovannitti

12:00 Lunch

1:00 Drugs & Drug Regimens Dr. Ronald Kosinski

2:00 Alternatives - IV Sedation/GA Options

3:00 Break

3:15 Monitoring Dr. Ernie Luce

3:45 Non-Pharmacologic Behavior Management Dr. David Rothman

Saturday, March 5, 2016

8:00 Treating Disabled Patients Dr. David Rothman

9:00 Human Simulation Dr. Ronald Kosinski

10:00 Break

10:15 Medical Emergencies

12:00 Lunch

1:00 Children with Medical Challenges Dr. David Rothman

2:45 Break

3:00 Pediatric Sedation for the Autistic Patient Dr. Ronald

Kosinski

David L. Rothman, D.D.S. - Chair Las Vegas Pediatric Sedation Review Course 2016

Speakers & Topics Subject to Change

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Pain control during dental procedures is typically well controlled with the use of local anesthetic agents. However, it is well known that certain procedures are also associated with a degree of postoperative pain. The removal of impacted

third molars is a classic example of a procedure that is predicted to have an associated period of postoperative discomfort. The management of acute pain in the perioperative period may involve prescribing an opioid analgesic in conjunction with other over the counter medications (such as NSAIDs or acetaminophen).

The prescribing of opioid analgesics is not without concern as the diversion of these medications to other individuals or use for non-indicated reasons is a significant health issue. The doctor is in a quandary as failure to prescribe an adequate amount of an opioid may lead the patient to unnecessarily suffer but excessive quantities left over from the recovery period may encourage diversion. Some studies show that over 42% of prescribed opioid analgesics are not used. The restriction on telephoning in additional prescriptions also leads to a trend of higher quantities being prescribed.

Concerns with leftover medications include the inappropriate use by the patient for whom the drug was prescribed. In addition, many pediatric patients have other siblings or visitors to the home that may abuse the medications. Even pets have been poisoned.

Therefore it is important for the patient or patient’s family to be instructed on the disposal of medications once recovery from the initial procedure is completed. The FDA has information on their website (http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm101653.

htm) on means to dispose of unused medications. In summary there are 3 techniques:

1. Flush down the toilet. Many drugs can be harmful to susceptible individuals even with a single dose. For these dangerous medications the FDA recommends flushing down the toilet. Examples include meperidine, oxycodone and hydromorphone. There is the concern of environmental pollution and indeed some levels of prescription medications have been detected in streams and rivers. However, these levels are believed to be due to normal human excretion of medication as opposed to disposal.

2. Dispose in trash. Certain medications, considered less hazardous, can be disposed of in the normal household waste. Of course the medication should be removed from the original packaging and mixed with an unpalatable agent such as kitty litter, coffee grounds or soil. The medications should be mixed well to avoid the potential for re-use.

3. Community take back programs. This is considered the most ideal way to dispose of prescription medications. Many police departments will anonymously accept medications for disposal. Other resources include large pharmacy chains.

Just as it’s important for the health care provider to give clear instructions on the use of medications, there also should be discussions on the need to dispose of excess medications. In our practice, when patients return for follow up examinations, a discussion regarding pain is conducted. If the patient is no longer in discomfort, the patient or parent is instructed on the need to dispose of the remaining analgesics.

In conclusion, the dentist needs to consider the analgesic needs for their patients. Strategies such as the use of pre-emptive non-steroidal medications, utilizing long acting local

Stuart Lieblich, D.M.D.

Opioid Prescribing in the Pediatric Populationby Stuart Lieblich, D.M.D.

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Most medication administered to children is dosed according to weight. This is especially true of emergency medications which, when necessary, must have their dose calculated, drawn up and administered quickly;

often in times of stress for the dental team. To prevent mathematical errors, save valuable time, and ensure the correct dose of medication, a pediatric emergency drug calculator has been developed utilizing Microsoft Excel® software . The preoperative weight of the child is entered into the calculator which then calculates the appropriate dosages of common emergency drugs. These values can be written on a dry erase board and hung in the surgical suite, or simply printed and placed near the emergency medications or crash cart for use by the anesthesia team. In addition to the correct dosage of emergency

drugs for that particular child, maximum dosages of local anesthetics, maximum fluid volumes and defibrillation settings are pre-calculated as well. Pre-loading syringes of specific drugs can also save valuable time should the need arise. In addition, office emergency drills can be performed using simulated dosages from the calculator and expired emergency drugs to ensure doctor and staff are familiar with loading syringes with the varying volumes of drugs used during pediatric emergencies.

Most children’s hospitals use a similar protocol by pre-calculating emergency drug dosages, based on the child’s weight, and placing that information in the patient record. Anesthetic

emergencies in children can develop and progress quickly. Having the correct emergency drug dosages pre-calculated and pre-drawn can save valuable time and will lead to improved outcomes during pediatric anesthetic emergencies. The calculator is available in the reference section of the ADSA web site, www.adsahome.org.

anesthetics (when appropriate) and having the patient use an NSAID on a timed basis vs. “p.r.n.” have been shown to improve outcomes. New research with the use of sustained release local

anesthetics (EXPAREL®, Pacira Pharmaceuticals) may improve patient outcomes and reduce the need for opioid analgesics.

Opioid Prescribing in the Pediatric Populationby Stuart Lieblich, D.M.D.

Practice Pearl: Pediatric Emergency Drug Calculatorby Michael Rollert, D.D.S.

Michael Rollert, D.D.S.

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News Briefs

ADA House Sends Anesthesia Guidelines Back to CDELThe ADA House of Delegates narrowly passed a Reference Committee resolution referring proposed changes to the ADA sedation and anesthesia guidelines back to the Council on Education and Licensure (CDEL) for further revision.

After a year-long comprehensive review of the guidelines by CDEL and its Committee on Anesthesiology, which included input from the communities of interest, Resolution 77 was submitted to the ADA House of Delegates which would have made numerous changes in the guidelines. Those changes included mandating end tidal CO2 monitoring for moderate sedation, requiring like-training for both enteral and parenteral moderate sedation, requiring an intravenous access site for all routes of parenteral moderate sedation, and changes to the requirements for pre-operative patient evaluation along with other more subtle modifications.

The ADA Reference Committee heard testimony before a packed house during a lively two hour session which resulted in their submission of substitute resolution 77RC which was passed by the House of Delegates two days later. The substitute resolution referred the proposed guidelines back to CDEL to consider eliminating the mandate for end tidal CO2 monitoring for monitoring ventilation during moderate sedation and allow for the choice of end tidal CO2 monitoring, auscultation of breath sounds, or verbal communication with the patient; to reconsider the concept of like-training for all administrative routes of moderate sedation; and to make patient evaluation provisions consistent throughout the documents.

The resolution called for CDEL to report its recommendations to the 2016 House of Delegates in Denver, CO.

Teen’s Dental Visit Changes State Law

Illinois Governor Bruce Rauner, recently signed legislation requiring insurance policies in that state to cover sedation for routine dental care of children with autistic spectrum disorder and other developmental disabilities until age 19. Previously, the state only required insurance companies to cover sedation care until age 6.

The legislation was the result of work by Mike Baker of Schaumburg, IL, whose teenage son Bryan, diagnosed with autistic spectrum disorder, required sedation for routine dental care. The absence of insurance coverage resulted in additional out of pocket expenses for the Baker family.

Baker met with local lawmakers to address the issue which resulted in legislation passed by the Illinois Legislature and signed by the Governor. The new law takes effect January 1, 2016.

Although Governor Rauner’s signature did not come with an official message, Baker was thankful to lawmakers and advocates for their support. “I hope it affects a lot of people,” Baker said.

FDA Approval of Sugammadex Appears ImminentIn November, a panel of the US Food and Drug Administration (FDA) recommended approval for sugammadex (Bridion - Merck) for reversal of moderate to deep neuromuscular blockade induced by rocuromium or vecuronium used during anesthesia. The FDA’s Sugammadex Injection Anesthetic and Analgesic Drug Products Advisory Committee concluded that “the benefits of sugammadex markedly outweigh its risks, and sugammadex represents an important addition to the pharmacologic interventions available for patients undergoing anesthesia with NMB in the surgical setting.”

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News Briefs

The FDA is not bound by the committee’s guidance but takes its advice into consideration when reviewing investigational medicines. The action date for the FDA’s review of Bridion is Dec. 19, 2015.

“We believe that Bridion has the potential to offer anesthesia professionals an important new option to reverse neuromuscular blockade in the surgical setting,” said Dr. David Michelson, head of global clinical development for neuroscience, Merck Research Laboratories. “Today’s discussion is one step in the regulatory process, and we look forward to working with the FDA as it completes the review of our New Drug Application for Bridion.”

If approved, Bridion would be the first in a new class of medicines, known as selective relaxant binding agents, to be used in the U.S.

American Heart Association Updates GuidelinesThe American Heart Association (AHA) recently published updated guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) for both pediatric and adult patients that make subtle changes to resuscitation practice and training.1

The key issues and changes for pediatric BLS-HCP include:

• Reaffirming the C-A-B sequence as the preferred sequence for pediatric BLS.

• Establishing a new algorithm for 1-rescuer and multiple-rescuer pediatric BLS-HCP in the cell phone era.

• Establishing an upper limit of 6 cm for chest compression depth in adolescents.

• Increasing the chest compression rate to between 100 and 120 compressions per minute.

• Strongly reaffirming that compressions and ventilation are needed for pediatric BLS.

Changes to the Pediatric Advanced Life support (PALS) algorithms should be viewed more as refinements rather than new recommendations. They include:

• Recommending restrictive volumes (instead of aggressive volumes) of isotonic crystalloids in pediatric patients with febrile illnesses.

• Cautioning against the routine use of atropine as a premedication for emergency intubation, specifically to prevent arrhythmias.

• Accepting either amiodarone or lidocaine as an acceptable anti-arrhythmic agent for shock-refractory pediatric VF and pVT.

• Continuing to recommend epinephrine as a vasopressor in pediatric cardiac arrest.

The full summary of refinements and changes for both pediatric and adult BLS-HCP and Advanced Life Support (PALS/ACLS) can be viewed in the reference section of the ADSA web site www.adsahome.org.

1. Neumar RW, Shuster M, Callaway CW, et al. Part 1: executive summary: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(18)(suppl 2).

Nominations DueNominations for two (2) open director positions will be accepted from ADSA members in good standing until February 6, 2016. Nominees must be ADSA members in good standing.

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Pregnancy outcome after in utero exposure to local anesthetics as part of dental treatment: a prospective comparative cohort studyAharon Hagai, DMD, Orna Diav-Citrin, MD, Svetlana Shechtman, PhD, Asher Ornoy, MDJADA, Volume 146, Issue 8, Pages 572–580

BackgroundDental treatment and use of local anesthetics during pregnancy generally are considered harmless because of lack of evidence of adverse pregnancy effects. Data on the safety of dental treatment and local anesthetics during pregnancy are scant. Dental care is often a reason for concern both among women and their health care providers. The primary objective of this study was to evaluate the rate of major anomalies after exposure to local anesthetics as part of dental care during pregnancy.

MethodsThe authors performed a prospective, comparative observational study at the Israeli Teratology Information Services between 1999 and 2005.

ResultsThe authors followed 210 pregnancies exposed to dental local anesthetics (112 [53%] in the first trimester) and compared them with 794 pregnancies not exposed to teratogens. The rate of major anomalies was not significantly different between the groups (4.8% versus 3.3%, P = .300). There was no difference in the rate of miscarriages, gestational age at delivery, or birth weight. The most common types of dental treatment were endodontic treatment (43%), tooth extraction (31%), and tooth restoration (21%). Most women (63%) were not exposed to additional medications. Approximately one-half (51%) of the women were not exposed to dental radiography, and 44% were exposed to radiation, mostly bite-wing radiography.

ConclusionsThis study’s results suggest use of dental local anesthetics, as well as dental treatment during pregnancy, do not represent a major teratogenic risk.

Practical ImplicationsThere seems to be no reason to prevent pregnant women from receiving dental treatment and local anesthetics during pregnancy.

Effect of preoperative oral midazolam sedation on separation anxiety and emergence delirium among children undergoing dental treatment under general anesthesiaHisham Yehia El Batawi, BDS MDS PhDJ Int Soc Prev Community Dent. 2015 Mar-Apr;5(2):88-94.

Aim:To investigate the possible effects of preoperative oral Midazolam on parental separation anxiety, emergence delirium, and post-anesthesia care unit time on children undergoing dental rehabilitation under general anesthesia.

Methods:Randomized, prospective, double-blind study. Seventy-eight American Society of Anesthesiology (ASA) I children were divided into two groups of 39 each. Children of the first group were premedicated with oral Midazolam 0.5 mg/kg, while children of the control group were premedicated with a placebo. Scores for parental separation, mask acceptance, postoperative emergence delirium, and time spent in the post-anesthesia care unit were compared statistically.

Results:The test group showed significantly lower parental separation scores and high acceptance rate for anesthetic mask. There was no significant difference between the two groups regarding emergence delirium and time spent in post-anesthesia care unit.

Conclusions:Preoperative oral Midazolam could be a useful adjunct in anxiety management for children suffering dental anxiety. The drug may not reduce the incidence of postoperative emergence delirium. The suggested dose does not seem to affect the post-anesthesia care unit time.

Abstracts

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Pulp cells are essential for tooth development, and dentin repair and regeneration. In addition these cells have been identified as an important stem cell source. Local anesthetics are widely used in dental clinics, as well as the other clinical disciplines and have been suggested to interfere with human permanent tooth development and induce tooth agenesis through unknown mechanisms. Using pig model and human young permanent tooth pulp cells, our research has identified that the local anesthetics commonly used in clinics can affect cell proliferation. Molecular pathway profiling suggested that LC3II is one of the earliest molecules induced by the agents and p62 is the only common downstream target identified for all the drugs tested. The effect of the drugs could be partially recovered by V-ATPase inhibitor only if early intervention is performed. Our results provide novel evidence that local anesthetics could affect tooth cell growth that potentially can have impacts on tooth development.

Local anesthetic may affect development of children’s teethH Zhuang, D Hu, D Singer, J V Walker, R B Nisr, K Tieu, K Ali, C Tredwin, S Luo, S Ardu & B HuCell Death Discovery (2015) 1, 15024; doi:10.1038/cddiscovery.2015.24; published online 7 September 2015

Abstracts

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The International Federation of Dental Anesthesiology Societies (IFDAS) held its 14th Triennial International Dental Congress on Anesthesia, Sedation and Pain Control on October 8-10, 2015 in Berlin, Germany. The meeting was hosted by Breufsverband Deutscher Oralchirugen (BDO – German Oral and Maxillofacial Surgery) President Dr. Wolfgang Jakobs, Deutsche Gesellschaft fur Mund, Kiefer und Gesichtschirurgie (DGMKG – German Society for Facial, Jaw, and Maxillofacial Surgery) President Dr. Lur Koper, and IFDAS.

IFDAS President-elect Dr. Bilal Al-Nawas of Germany chaired the successful Congress, which attracted participants from twenty-one countries. The Congress featured programs on local anesthesia techniques, care of medically compromised patients, sedation in dentistry and oral surgery, emergency medicine, and alternative methods of anxiolysis, sedation and pain reduction.

High-fidelity emergency team simulation and airway management workshops were offered in both English and German. Workshop participants were placed into realistic clinical simulations representing emergencies commonly encountered during all levels of sedation and trained in emergency management principles.

IFDAS continues to collaborate with the ADSA Anesthesia Research Foundation on the

“Ten Minutes Saves a Life!” patient safety initiative. Evolving plans were discussed at the Congress to continue development of the emergency crisis resource management team training programs into German, Japanese, and Russian. To complement this, the Congress featured a Critical Incident Initiatives session on global developments. Presenters from the United Kingdom, United States, Israel, Russia, Australia, Mexico, Japan and Germany reviewed their country’s standards for emergency crisis resource management.

The IFDAS Horace Wells Award, the highest recognition the Society presents to outstanding practitioners who have served their colleagues and profession with steadfast enthusiasm, dedication, and integrity in the area of dental sedation and anesthesia was presented to Dr. Christine Quinn of the U.S. and Dr. Monika Daublander of Germany. The inaugural IFDAS Badge of Honor: Kubota Distinguished Service Award, the highest recognition to outstanding practitioners for their dedicated service to IFDAS was presented to Dr. Joel Weaver of the U.S. and Dr. James Grainger of Australia.

IFDAS President Dr. Jim Phero and IFDAS Secretary General Professor Dr. Kazu-ichi Yoshida of Japan presided over the General Assembly, which elected Professor Dr. Tatsuya Ichinohe of Japan IFDAS President-elect and Dr. Karen Crowley as Americas Area Councillor. The 15th Triennial IFDAS Congress will be held October 5-7, 2018 in Nara, Japan hosted by the Japanese Dental Society of Anesthesia and the Federation of Asian Dental Anesthesia Societies.

IFDAS Triennial Congress Meets in Berlin, Germanyby Jason W. Brady DMD

Christine L. Quinn, D.D.S., M.S., IFDAS Horace Wells Award winner is congratulated by past winner Joel M. Weaver, D.D.S., PhD.

ADSA Leaders (L to R) attending IFDAS Berlin included Drs. Jason Brady, Chicago GA Course Chair; Kenneth Reed, ADSA President; Ronald Kosinski, ADSA Immediate Past President; William MacDonnell, former ADSA Pulse Editor; and Steven Ganzberg, Editor of ADSA’s Anesthesia Progress.

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The ADSA online programs are part of its mission to promote safe and effective patient care for all dentists who have an interest in anesthesiology, sedation and the control of anxiety and pain.

ON DEMAND CE Now On ADSAhome.org!

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