Anesthesia Management – Flashcards
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most commonly unmet need among the special needs population
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preventive dental care
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the number of Americans that have a disabling condition
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56 million
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what are some of the reasons mainstreaming is able to happen today?
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advances in psychoactive drugs; deinstitutionalizing; inclusion
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how has the number of institutionalized patients been affected since the 1970's?
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severely decreased
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by 2030, how many americans are estimated to be over the age of 65?
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70 million
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what age is the life expectancy projected to increase to by the year 2050?
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82.6
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what is the issue among dental students and treating patients with mental retardation?
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63% of dental students report never treating someone with mental retardation; 82% reported less than 5 hours of didactic time devoted to patients with ID
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why is there such a low priority for care of the special needs population? - knowledge - experience - office routine - equipment - compensation
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lack of knowledge; lack of experience; presumed interference with normal office routine; presumed need for additional equipment; inadequate compensation
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NDID
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neurodevelopmental intellectual disability
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4 pervasive developmental disorders
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PDD-NOS, aspergers, retts, CDD (childhood disintegrative disorder)
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one of the most common cases of autism
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Fragile X Syndrome
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characteristic of williams syndrome. what type of syndrome does this fall under?
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hyposocial; autism
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"self-hugging". what type of syndrome does this fall under?
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smith-magenis syndrome
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"happy puppet syndrome"; chromosome 15 abnormality. what syndrome does this fall under?
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angelman syndrome
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hyperphagia occurs with this syndrome. what syndrome category does this fall under?
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prader-willi syndrome. autism.
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what are some comorbidities that we see with autism?
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anxiety, ADHD, tourettes, OCD, depression, bipolar, seizures
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Mild, moderate, severe, profound ID ranges with respect to IQ.
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55-75: mild; 40-55 moderate; 25-40 severe; <25 profound
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what are some conditions that can be seen alongside intellectual disabilities?
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cerebral palsy, epilepsy, vision & hearing impairments, speech, language, and behavior problems
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most common type of cerebral palsy
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spastic
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cerebral palsy that involves twitching, jerking, uncontrolled limb, head & eye movement
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dyskinetic
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cerebral palsy associated with tremors and poor sense of balance
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ataxic cerebral palsy
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x-linked recessive genetic disease involving progressive skeletal muscular weakness and degeneration.
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muscular dystrophy
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most significant type of muscular dystrophy
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Duchenne's Muscular Dystrophy
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which gender is muscular dystrophy more common in and why? what is a muscle in particular that can be affected and lead to more serious problems?
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males. it is an x-linked recessive disorder so if they get one copy they will still acquire the trait. the respiratory muscles can be affected which can lead to a loss of pulmonary reserve - ability to clear secretions & cough reflex is decreased.
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why can there be an issue with the lungs in those patients with muscular dystrophy?
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inability to clear secretions and their coughing reflex is reduced
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what reflex is diminished in those with muscular dystrophy?
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coughing reflex and inability to clear secretions
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what type of infections are those with muscular dystrophy prone to?
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pulmonary
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volume of air present in the lungs at the end of passive expiration. who can this be decreased in?
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FRC - functional residual capacity. those with muscular dystrophy.
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kyphoscoliosis is associated with which disorder? what can it result in?
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seen in muscular dystrophy; leads to restricted lung expansion and even further FRC (functional residual capacity)
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most patients with this disorder are succumbed to respiratory failure, pneumonia, and/or congestive heart failure
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muscular dystrophy
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approximately 50% of down syndrome patients experience what other problem?
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congenital heart defects: ASD, VSD, Patent ductus arteriosis, tetralogy of fallot
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down syndrome - -weight -infections -immune system -seizures -thyroid -indigestion -muscles/skeletal -sleeping -blood glucose -mentality disorders
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overweight (obesity); prone to infections due to decreased immune system; increased seizures; hypothyroidism; GERD; musculoskeletal problems; sleep apnea; diabetes; alzheimers
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which syndrome do you have to be careful laying back in the dental chair and why?
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down syndrome - atlantoaxial instability (C1 does not click into C2)
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what two things in down syndrome can increase the patient's risk for aspiration?
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GERD & airway hypotonia
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what is the issue with many anti-seizure drugs and metabolism? what drug can this have an effect on and how?
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anti seizure drugs induce the CYP34 pathway of the liver. benzos are metabolized through this pathway so increasing the speed with increase the speed of the benzo metabolism. Increasing the speed of benzo metabolism will decreases their efficacy.
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drug that reverses benzodiazapines. what is the concern with this and someone taking a benzodiazapine for their seizures?
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flumazenil. If someone is taking a bento to control their seizures and flumazenil is administered, they can trigger a seizure in this individual.
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where can the basic oral health care needs of patients with special needs be met? (unlike many would think...)
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in a regular dental office without sedation
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who made the guidelines for anesthesia for those with special healthcare needs?
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SCDA - special care dentistry association
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SCDA Guidelines for Anesthesia: -impairment -feelings about treatment -sitting ability -degree of dental needs -local anesthesia -medical state
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cognitive impairment, fear of dental treatment, inability to sit still, extensive dental needs, inability to achieve local anesthesia, medical complexity
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why are those with SHCN treated as outpatients with regards to anesthesia?
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To avoid disrupting their normal routine & promotes behavioral and emotional stability.
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Benefits of anesthesia: - treatment planning - time - preparation of patient
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allows implementation of original treatment plan; allows for procedures to be performed in a timely manner; prepares patient for future treatment without anesthetic interventions
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4 anesthetic techniques
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premedication; deep sedation with open airway; TIVA (total intravenous anesthesia) with LMA (laryngeal mask airway) or endotracheal tube; endotracheal anesthesia with inhalational agents
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often given to those with SHCN for sedation, transport to operatory, or IV placement. what are the two routes of administration for this?
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ketamine/midazolam. IM or oral
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"The Fab Four" premeds for SHCN
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midazolam, triazolam, lorazepam, diazepam
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3 of the fab four that have a contraindication of allergy and acute narrow angle glaucoma
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midazolam, lorazepam, diazepam
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pregnancy category X pre-med
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triazolam
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shortest premed onset of the fab four but also the shortest duration
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midazolam
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anti-anxiety med used for premed
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diazepam
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what is a precaution with diazepam?
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sedation intensified with CYP34A inhibitors & CYP2C19
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premed well tolerated in the elderly
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lorazepam
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precautions of lorazepam. what two classifications is this given?
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over sedation, depressive disorders, psychosis; sedative/hypnotic; anti anxiety.
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premed usually used in children
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midazolam
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triazolam precaution in the elderly. classification of this drug?
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excessive sedation in the elderly. triazolam is a sedative/hypnotic.
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the fab four drug with active metabolites
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diazepam
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parenteral dose form of ketamine. what is the benefit of this mix?
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ketamine/midazolam. rapid onset.
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peak plasma concentration of ketamine: - IV - IM - Oral what is the stun dose?
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IV: 1 minute - IM: 5 minutes - oral: 30 minutes - stun dose: enough of the drug to gain compliance but not necessarily to a total anesthetic state
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most common fab four drug used in the special needs population
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diazepam, lorazepam, triazolam, midazolam
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fastest acting IM anesthetic available
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ketamine
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ketamine amount given to gain compliance but not achieve a total sedated state. what is the problem with a very high dose of ketamine propose?
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stun dose. if given too much, it can impose a large problem of the person waking up.
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puts patient in a 'catatonic' state
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ketamine
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the ketamine dart
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ketamine, glylcopyrrolate, optional midazolam
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fentanyl use
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deep sedation
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midazolam use
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children
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ketamine use - three ways of use
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IV, IM, oral
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IV infusion or IV intermittent bolus used for deep sedation
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propofol
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IV infusion only - used for deep sedation
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remifentanil
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down syndrome and issues of airway
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large tonsils and maintaining an open airway
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"TIVA"
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total intravenous anesthesia - multiple drug infusions
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if we have trouble maintaining an open airway, what is usually used alongside the TIVA
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flexible LMA - laryngeal mask airway
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hooked to an IV pole when there is not anesthesia machine for the patient. it absorbs the CO2 and then recirculates it to the patient
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KAB Absorber
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when is emergence delirium needed to take place?
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when the patient wakes up very confused/angry/disoriented
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given to deal with emergence dilirium
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dexmedetomidine (presidex)
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mellowing agent for a patient waking up in serious delirium, which could result in them waking up angry
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dexmedetomidine (presidex)
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three sites of action for dexmedetomidine
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brain (local ceruleus), spinal cord, autonomic nerves
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Three effects that dexmedetomidine has on the CNS
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sedation/hypnosis; anxiolysis; analgesia
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effect of dexmedetomidine on the autonomic nerves
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sympathetic nervous system depressant. decrease heart rate and blood pressure
