Special Needs- Anesthetic Management – Flashcards
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Children with special health care needs
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-18% of all children have special health care needs -21.8% of households with children include at least one child with a special health care need -86% require prescription medications -52% require special medical care -most commonly mentioned unmet need is preventive dental care (16%)
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Americans with Disabilities
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*56 million Americans have disabling condition -25 million have a severe disability -10 million have a mental health problem -4 million Americans hav Alzheimers
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Mainstreaming
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-advances in psychoactive drugs -deinstitutionalization -inclusion -number of institutionalized patients with intellectual disabilities and developmental disabilities has decreased by 75% since the 70s
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Graying of America
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-more than 35 million people over the age of 65 in the united states -in 2011, the first members of the boomer generation reached age 65 -by 2030, 70 million over the age of 65 (1/5 Americans) -by 2050, life expectancy projected to increase to 82.6 years.
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Lack of Basic Knowledge
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-63% of dental students reported that they had never treated a patient with mental retardation -82% reported less than 5 hours of didactic time devoted to treatment of patients with mental retardation
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Low priority for care
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-lack of basic knowledge -lack of experience -assumed disruption of office routine -presumed need for facilities and equipment -inadequate compensation
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PDD
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Autism
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Cognitive disorders
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-NDID -Learning disorders -anxiety/ADHD/depression -emotional disturbances -Dementia -Traumatic brain injury
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Craniofacial Disorders
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cleft lip and palate
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Developmental disorders
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-CP -spina bifida
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Musculoskeletal disorders
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-muscular dystrophy -kyphoscoliosis -hemiplegia -paraplegia
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Syndromes
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-down -treacher-collins -autistic syndromes -fetal alcohol
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other special needs
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seizure disorders, vision, speech, hearing impairments
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Pervasive Developmental Disorders (PDD)
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-asperger syndrom -PDD-NOS -CDD -Rett syndrome
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Williams Syndrome
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-hyposocial
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Fragile X syndrome
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30% are autistic
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Smith-Magenis syndrome
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self-hugging
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Angelman syndrom
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-chromosome 15 abnormality -happy puppet syndrome
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Prader-Willi syndrome
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hyperphagia
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Comorbidity in Autism
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-anxiety -ADHD -OCD -Depression -bipolar disorder -Seizures
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Categories of ID
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associated with epilepsy, CP, vision and hearing impairments, speech and language and behavior problems
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Mild
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IQ 55-75 -89%
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Moderate
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IQ 40-55
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Severe
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IQ 25-40
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Profound
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IQ <25
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Major types of CP
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spastic, dyskinetic, ataxic, mixed
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Spastic CP
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most common
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Dyskinetic CP
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twitching, jerking, uncontrolled limb, head and eye movement
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Ataxic CP
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tremors, poor sense of balance
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Mixed CP
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Combination of above
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Muscular Dystrophy
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X-linked recessive genetic disease -Progressive skeletal muscular weakness and degeneration -weakness of respiratory muscles causes a loss of pulmonary reserve -Kyphoscoliosis develops -can lead to respiratory failure, pneumonia, and congestive heart failure
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pseudohypertrophic (Duchenne's) Muscular Dystrophy
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-1 in 3500 males, starting at a young age and becomes progressively debilitating with age. -Cardiac muscle progressively degenerates -decreased myocardial contractility and congestive failure -most significant type of MD
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Down Syndrome/Trisomy 21
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-1:800 births -50% have congenital heart defects (atrioventricular septal defects, atrial-septal defects, patent ductus arteriosis, ventricular septal defects, tetralogy of Fallot
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Things associated with Down Syndrome
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Obesity, respiratory infections, seizures, hematological and immunological problems, hypothyroidism, GERD, Musculoskeletal problems, OSA, diabetes, Alzheimer's disease
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Treatment Consideration in Down Syndrome
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-Risk of atlantoaxial instability (history, physician eval. with C-spine films, consider cervical collar.) -Physician consult for unrepaird cardiac defects -OSA issues -GERD and airway hypotonia increase risk of aspiration.
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Treatment considerations for pt. with Seizure disorders
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-Determine degree of control through history and physician consult -many anti-seizure drugs include CYP3A4 -Reversal of benzodiazepines in patients taking clonazepam may include seizures
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CYP3A4
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metabolism of benzodiazepines may be accelerated resulting in an incomplete, inadequate, or lessened effect.
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Need for sedation and anesthesia in the special needs population
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-The basic oral health care needs of patients with special needs can be met in traditional dental care settings. -A subset of patients will require treatment by clinicians with more advanced training and/or facilities.
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Goals of Sedation for Patients with Special Needs
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-facilitate the provision of quality dental care -minimize the extremes of disruptive behavior -promote a positive psychological response to treatment -promote patient welfare and safety -Return the patient to a physiologic state in which safe discharge is possible
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SCDA guidelines for Anesthesia
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-cognitive impairment -fear -inability to sit or remain still -extensive dental needs -inability to achieve adequate local anesthesia -medical complexity
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Anesthesia in the Special Needs Population enables...
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-outpatient service -initial treatment planning in patients with severe mental or behavioral impairment -initial treatment planning in patients with severe mental or behavioral impairment. -major treatment to be accomplished with minimal time allotment -prepares patient for future treatment without anesthetic interventions
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Anesthesia in the special needs population
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-cooperation related to level of sedation -deep sedation or general anesthesia -difficult airways are the norm (may deteriorate during dental treatment) -must have several induction options ready to go.
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Anesthesia techniques
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premedication, deep sedation with open airway, TIVA with LMA or endotracheal tube, endotracheal anesthesia with inhalational agents.
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Sedative Premedication
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Indications -pre-anesthetic sedation/anxiolysis -IV placement Route of Administration -enteral -intramuscular
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The fab four
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Diazepam, Lorazepam, Triazolam, Midazolam
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Diazepam Dosage
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2-10mg adults 0.15-0.3 mg/kg children
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Diazepam Onset
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1 hour, 2 hours peak
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Diazepam Duration
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1-3 hours
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Diazepam Contraindications
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allergy, acute narrow angle glaucoma
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Diazepam Precautions
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sedation intensified with CYP3A4 and CYP2C19 inhibitors
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Diazepam Availability
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2, 5, 10 mg tablets 10 mg/5ml syrup
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Diazepam Pregnancy category
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D
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Diazepam active metabolites?
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yes
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Diazepam classification
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anti-anxiety
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Lorazepam Dosage
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2-4 mg adult well tolerated in the elderly
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Lorazepam onset
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1-2 hours
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Lorazepam duration
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2-4 hours
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Lorazepam Contraindications
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allergy acute narrow angle glaucoma
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Lorazepam Precautions
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- oversedation -depressive disorders -psychosis
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Lorazepam Availability
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0.5, 1, 2, mg tablets
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Lorazepam Active metabolites?
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no
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Lorazepam Pregnancy category
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D
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Lorazepam Classification
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anti-anxiety sedative/hypnotic
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Triazolam Dosage
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0.25- 0.5 mg adults
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Trizolam onset
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1 hour
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Triazolam Duration
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1 hour
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Triazolam Contraindications
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pregnancy
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Triazolam Precautions
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excessive sedation possible in elderly
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Triazolam Availability
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0.125, 0.25 mg tablets
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Triazolam active metabolites?
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no
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Triazolam pregnancy category
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X
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Triazolam Classification
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sedative/hypnotic
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Midazolam Dosage
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0.25- 1.0 mg/kg children 20 mg max
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Midazolam Onset
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15-30 minutes
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Midazolam Duration
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30 minutes- 1 hour
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Midazolam Contratindications
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-allergy -acute narrow angle glaucoma
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Midazolam Precautions
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sedation intensified by CYP3A4 inhibitors
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Midazolam Availability
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-2 mg/ml syrup -5 mg/ml parenteral
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Midazolam active metabolites?
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no
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Midazolam pregnancy category
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D
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Ketamine/Midazolam
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-parenteral dose form of ketamine -dosage (ketamine: 4 mg/kg, midazolam: 0.4 mg/kg) -rapid onset
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Ketamine
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-pharmacokinetics -1-2 mg/kg IV -4-6 mg/kg IM (2-3 mg/kg IM "stun dose"
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Pharmacokinetics of ketamine peak plasma concentration
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-1 minute IV -5 minutes IM - 30 minutes oral
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Pharmacokinetics of ketamine redistribution
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-15 minutes IV -30-120 minutes IM
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The ketamine dart
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-ketamine (2-3 mg/kg) -glycopyrrolate (0.003 mg/kg) -optional midazolam (0.05 mg/kg)
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Deep Sedation
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-Fentanyl -Midazolam Ketamine (IM, IV intermittent bolus, IV infusion) -Propofol (IV infusion, IV intermittent bolus) -remifentanil (IV infusion)
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Dentistry as an airway insult
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-airway manipulation -rubber dam -handpiece with water spray -indiscriminate rinsing -bleeding -tongue retraction
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Emergence Delirium- mechanism of action
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sites of action (brain- locus ceuleus, spinal cord, autonomic nerve
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Emergence Delirium- CNS
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-sedation/hypnosis -anxiolysis -analgesia Autonomic nerves ↓ sympathetic activity ↓ BP & HR
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Dexmedetomidine for Emergence Delirium
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100 mcg/ml - 2 ml vial -200 mcg Dilute vial to 50 ml -200 mcg in 50 ml -4 mcg/ml 0.25 mcg/kg slow bolus
