Pharmacologic Management of Patient

Behavior
Intern 董竑 /Moderator 賴俊成醫師

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Definition of Terms

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Pharmacologic management
• Pharmacologic management:
– These drugs can be administered through various routes, including inhalation, oral,
intravenous, and intramuscular methods. This management is divided into sedation and general
anesthesia.

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The continue of anesthesia and sedation
• Minimal sedation:
– maintain an airway independently and continuously
– respond normally to tactile stimulation and verbal commands
– cognitive function and coordination may be impaired
– ventilatory and cardiovascular functions are unaffected
• Moderate sedation:
– depression of consciousness during which patients respond purposefully verbal commands
– no interventions are required to maintain a patent airway, and spontaneous ventilation is
adequate
– cardiovascular function is maintained

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The continue of anesthesia and sedation
• Deep sedation :
– patients cannot be easily aroused but respond purposefully following repeated or painful
stimulation
– the ability to maintain ventilatory function independently is impaired
– cardiovascular function is usually maintained
• Administration Method Independence:
– Sedation levels are independent of the method of administration. Terms like "oral sedation" and
"IV sedation" are outdated and misleading.

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Fundamental Concepts

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The goals of sedation for the pediatric patient
• To guard the patient’s safety and welfare
• To minimize physical discomfort and pain
• To control anxiety, minimize psychological trauma, and maximize the
potential for amnesia
• To control behavior or movement so that the procedure can be
completed safely and
• To return the patient to a physiologic state in which safe discharge,
as determined according to recognized criteria, is possible

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Anatomic and physiologic difference
• Central Nervous System:
– Concerns about anesthetic toxicity : nonhuman primates have suggested possible neurotoxic
effects of anesthetic and sedative drugs on developing neurons
– Unclear conclusions
• Cardiovascular System:

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Anatomic and physiologic difference
• Respiratory System:
– Children have proportionally larger heads, shorter necks, and higher larynxes compared to
adults
– Factors such as narrow nasal passages, large tongues, and enlarged tonsils increase the risk
of airway blockage

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Anatomic and physiologic difference
• Body Size and Composition:
– Impact on sedation and anesthesia: Increased adiposity can complicate airway management
and increase the likelihood of obstructive sleep apnea, affecting both sedation and recovery.
– Challenges in Emergencies: Obesity can make venous access more difficult and complicate
resuscitation, making it essential for the dental team to be prepared to handle and move obese
children if unconsciousness occurs.

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Routes of drug administration
• Inhalational Route:
– rapid absorption of nonirritating gases and volatile drugs
• Enteral Route:
– simple and inexpensive, but their effects can be less reliable due to factors like limited
absorption, destruction by digestive enzymes, and first-pass metabolism in the liver.
– Taste and cooperation can be issues
• Intramuscular Route:
– relies on muscle vascularity for a relatively rapid onset (5-10 minutes). It provides faster and
more predictable sedation than oral techniques but still limits the practitioner to a single dose.
• Submucosal and Subcutaneous Routes:
– depositing the drug under the oral mucosa

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Routes of drug administration
• Intravenous Route:
– rapid drug delivery to the brain within 20-40 seconds, with easily titratable sedation and faster
recovery compared to oral or intramuscular routes. It allows multiple doses with high control
and flexibility.
• Rectal Route:
– unsuitable for pediatric sedation.

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Drugs and agents used for sedation
• Nitrous Oxide:
– rapid onset and ease of administration, usually achieving sedation within 3-5 minutes.
– It produces relaxation and mild euphoria but can cause nausea and vomiting, especially at
concentrations above 50%.

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Antihistamine
• Hydroxyzine (Atarax, Vistaril):
– sedative, anticholinergic, and antiemetic effects
– Absorption occurs within 15-30 minutes, with peak effects at 2 hours
• Promethazine (Phenergan):
– rapidly absorbed, with effects starting at 20 minutes and peaking at 2-3 hours
– Side effects include blurred vision, prolonged drowsiness, and ataxia
• Diphenhydramine (Benadryl):
– One of the most commonly used antihistamines for pediatric sedation and antiemetic therapy
– Peak effects occur around 1 hour

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Benzodiazepine agonists and antagonists
• Clinical Effects:
– anxiolysis, hypnosis, amnesia, muscle relaxation, and anticonvulsant activity
– do not provide analgesia
• Diazepam, Valium:
– provides rapid and sustained anxiolysis but poses a risk of prolonged sedation and airway
obstruction
• Midazolam (Versed):
– Sedation onset occurs within 20-30 minutes, providing around 30 minutes of working time
• Flumazenil, Romazicon:
– Intravenous administration is recommended

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Opioid agonists and antagonists
• Opioids:
– pain modulation, breathing, digestion, and stress response
– respiratory depression and nausea.
– provide analgesia without affecting memory or awareness, while benzodiazepines mainly
induce amnesia
• Fentanyl (Sublimaze):
– acts rapidly, with onset in 7–15 minutes and a duration of 1–2 hours.
• Meperidine (Demerol):
– Oral administration is about half as effective as intramuscular injection, with peak effects at
around 60 minutes.
– contraindicated for patients with liver disease, kidney disease, or seizure disorders.
• Naloxone (Narcan):
– used to reverse opioid overdose.

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Other sedative-hypnotics
• Chloral Hydrate:
– Children often experience a period of disinhibition (excitement and irritability) before sedation.
Large doses can sensitize the myocardium to epinephrine, leading to arrhythmias. The lethal
dose is about 10 g in adults, but fatalities have occurred with as little as 4 g.

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Nitrous Oxide Administration

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Objectives
• Advantages:
– Reducing or eliminating anxiety
– Reducing untoward movement and reaction to dental treatment
– Enhancing communication and patient cooperation
– Raising the pain threshold
– Increasing tolerance for longer appointments
– Aiding in the treatment of a patient with mental and/or physical disabilities or a medically
compromised patient
– Reducing gagging
– Potentiating the effects of sedatives
• Disadvantages:
– Lack of potency
– Dependence on psychological reassurance
– Interference of the nasal hood with injection to the anterior maxillary region
– Need for the patient to be able to breathe through the nose
– Nitrous oxide pollution and potential occupational expo sure health hazards
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Equipment
• Safety Requirements:
– Machines must have a high-flow oxygen flush valve and be capable of delivering 100% oxygen
for pediatric emergencies.
• Proportioning Systems:
– Fail-safe mechanisms prevent oxygen concentrations from dropping below 30%. If nitrous
oxide exceeds 70%, an inline oxygen analyzer is required.
• Scavenging Systems:
– To reduce occupational exposure, systems like the double-mask scavenger are recommended.
Exhaust should be vented outside to prevent room contamination.
• Pin Index Yoke System:
– Ensures gas tanks align correctly, reducing the risk of gas tank crossover errors, which can
occur during renovations or with worn fittings.

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Monitoring and Documentation
• Continuous Monitoring:
– patient’s responsiveness, skin color, respiratory rate, and rhythm.
• Documentation
– The percentage of nitrous oxide used, flow rate, procedure duration, and post-treatment
oxygenation must be documented

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Enteral Sedation Technique

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Enteral Sedation Technique
• Administration and Monitoring
• Nitrous Oxide Use
• For short procedures

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Enteral Sedation Technique

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Combinations of Methods and Agents

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Combinations of Methods and Agents
• Pain and Nociception:
– No single drug neutralizes all components, making drug combinations more effective for
moderate sedation in pediatric dentistry.
• Local Anesthesia:
– Local anesthetics block nociception and are an integral part of sedation, preventing the
sensation of pain and improving outcomes when combined with other sedatives.
• Nitrous Oxide:
– rapid onset, control, and reversibility, making it a safer option compared to dose-stacking with
oral sedatives.

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Combinations of Methods and Agents
• Drug Combinations:
– midazolam with meperidine or hydroxyzine, have shown effectiveness but require further study,
particularly concerning safety and the role of opioids in sedation protocols. Interactions
between opioids and local anesthetics can increase the risk of toxicity.

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Facilities and Equipment
• Quiet Room:
– helps minimize distractions and focus on sedation procedures. The facility should be equipped
to handle sedation emergencies, especially those involving airway compromise.
• Required Equipment:
– adequate suction, monitoring devices, and a positive-pressure oxygen system

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Documentation
• Preprocedural Records:
– adherence to food and liquid intake restrictions
– preoperative health evaluation, including the patient’s health history and a complete physical
assessment along with the patient’s current weight, age, and baseline vital signs;
– name and address of the physician who usually cares for the child;
– a note as to why the particular method of management was selected;
– documentation of informed consent; and
– the delivery of instructions to the caregiver. Before the procedure is undertaken, a “time out”
should be performed to confirm the patient’s name, procedure to be performed, and site of the
procedure.
• Intraoperative Records
• Postoperative Care

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Patient Selection and Preparation
• Indication:
– No single drug, combination, or technique guarantees success every time. The dentist should
choose the method that best fits the patient and the procedure. Behavioral or anxiety
assessments can help guide the choice, but experience and intuition play significant roles.

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Preoperative Evaluation
• Medical History
• Physical Evaluation
• Behavioral Assessment:

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Informed consent
• Documentation:
– The consent form should include the parent’s/guardian’s signature, the date consent was
obtained, and the planned sedation date. If consent was obtained prior to the procedure, it
should be reaffirmed on the day of the procedure.

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Instructions to parents
• Preoperative Dietary Guidelines:
– Clear liquids up to 2 hours before the procedure.
– Breast milk up to 4 hours before.
– Infant formula and nonhuman milk up to 6 hours before.
– A light meal up to 6 hours before, avoiding fatty foods that delay gastric emptying.
– Routine medications can be taken with a small amount of water on the day of the procedure.
• Transport and Postoperative Care:
– Parents should remain in the office during the procedure
– the child may be sleepy or irritable, and frequent observation is required.

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Monitoring

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Intraoperative monitoring
• Oxygenation, Ventilation, and Circulation:

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Postoperative monitoring
• The child must be alert, able to speak, walk with minimal assistance, and
sit unaided. The child should also remain awake for at least 20 minutes
before discharge.

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Concluding Thoughts

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• Primum non nocere (First, do no harm)
• Airway management supersedes pharmacologic management:
• Appreciate the limits of moderate sedation

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Thank you for your attention ！

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