PremedicationPain managment

Measurement of pain in children

• Observer-based techniques which are useful in pre-verbal children, blood pressure, crying, movement, agitation and verbal expression/body language.

• Self-reporting of pain is valid in children over 4–5 years of age. • Older children and teenagers can use a normal visual analogue

scale of 1–10.• Mentaly handicaped children - difficult to assess - unusual

changes in behaviour

Analgesia prior to procedures (pre-emptive analgesia)

• ensure adequate systemic and/or local analgesia prior to the commencement of a procedure

• Appropriate time for absorption and effect should be allowed.• A stronger analgesic may be required for the procedure with

regular simple analgesics for the postoperative period.

Routes of administration• Per os - is the preferred route of administration in children. • absorption for most analgesics is generally rapid – within 30min• liquid vs. tablets in younger children, taste - can help greatly with

compliance• Per rectum - in a child who is fasting or not tolerating oral fluids. • peak levels are usually much longer (paracetamol 90–120 min)

- not used in the immunocompromised child due to the risk of infection

• Intranasal or sublingual - as an alternative• Intramuscular injection should be avoided in children• In obese children, the dosage given should be based on ideal

body weight

Paracetamol• pre-op 20 mg / kg po (syrup) • Post-op 15 mg / kg po á 6 hours. • (30 mg / kg as a single dose rectally) maximum 24-hour dose

90mg/kg, followed by 50 mg / kg / d! • from 3.months of age

• ! Watch out in hepatopathy• Useful as a pre-emptive analgesic• No effect on bleeding• IV paracetamol (PERFALGAN) in hospitalised

NSAID - ibuprofen• Pre-op - ibuprofen 10mg/kg p.o. (syrup)• Post-op – if needed ibuprofen 5 mg/kg á 6-8 hod. p.o.

• Effective alone after oral and dental procedures.• Can be used in conjunction with paracetamol.• Have an opioid-sparing effect.• Increase bleeding time due to inhibition of platelet

aggregation.• Useful analgesic once haemostasis has occurred.• Best given if tolerating food and drink.• Can be used in infants over 3 (some authors 6) months of age.

Non-steroidal anti-infl ammatory drugs (NSAIDs)

NSAIDs are contraindicated in children with:• Bleeding or coagulopathies.• Renal disease.• Haematological malignancies, who may have or develop

thrombocytopenia.• Asthma, especially if they are sensitive to asthma, steroid-

dependent or have coexisting nasal polyps.

Sedation in paediatric dentistry

• The choice of a particular technique, sedative agent and route of delivery

• children’s responses are more unpredictable than adults - easily over-sedated

Anatomical differences between the adult and the paediatric airways include:• Children have a relatively larger tongue and epiglottis.• Possible presence of large tonsillar/adenoid mass• The mandible is less developed and retrognathic in children.• Children have smaller lung capacity and reserve.

Patient assessment• Medical and dental history (including medications taken).• Patient medical status (American Society of Anaesthesiologists

(ASA) classifi cation).• History of recent respiratory symptoms or infections.• Assessment of the airway to determine suitability for

conscious sedation or general anaesthesia.• Fasting status• Procedure being performed• Age• Weight• Parent factors

Inhalation sedation- nitrousoxide sedation• Anxiolytic and mild analgesic effect• Anxious but cooperating children • Age - 4 years

Benefits • safe and relatively easy technique. • light sedation. • rapid onset (2-3min) and readily reversible with a short

recovery time (10-15min) • Entonox - titre fixed-N0 50%, 50% O2 • requires only clinical monitoring

Contraindications• Severe psychiatric disorders , mentaly handicaped• Obstructive pulmonary disease• Chronic obstructive airway disease• Communication problems• Uncooperating patients• Pregnancy• Acute respiratory tract infectionsComplications• nausea, vomiting• headache

Course of performance• healthy child (no colds, cough and / or fever),• not fasting, • Entonox - inhalation using a face mask or mouthpiece. • Maximum effect starts usually after 2-5min of uninterrupted

inhalation• Inhalation of Entonox continued intermittently throughout the

performance (application of local anesthesia, tooth extraction, surgery).

• After treatment - child is kept under supervision in a room of about 5 to 10 minutes or until his attention and motor coordination are sufficiently restored

Conscious sedation• patient who is awake, responsive and able to communicate• maintenance of protective reflexes• ! conscious sedation, deep sedation and/or general

anaesthesia is a continuum• Pulse oximetry• Age and size-appropriate equipment and medications for

resuscitation

Oral sedation

Premedication• Benzodiazepines (e.g. midazolam)

• Potentiated sedation– ANESTEZIOLOGIST• Chloral hydrate• Hydroxyzine• Promethazine• Ketamine

Midazolam - Dormicum• short-acting benzodiazepine • rapid patient recovery - extra sleep 2-3 hours • dosage ranges from 0.3 mg - 0.7 mg / kg • We 0.5 mg / kg • P.o. Dormicum tablets 7.5 mg or Midazolam 1 ml amp

• effects: • Sedative, hypnotic, anxiolytic, anterograde amnesia,

myorelaxant

Course of performance• The child must be healthy (no fever, cough, fever), • Fasting for min. 3 hours (6hrs). • With parent - short-term hospitalization,• midazolam administered as a solution or tablets (0.5 mg/kg) • under the supervision of accompanying person on a bed in

sleep-room. • onset of effect of midazolam - within 20-45 minutes the

followed by dental procedures (tooth extraction / s, tooth decay treatment, surgery)

• Recovery period 2-3hrs - under the supervision of accompanying person on a bed in sleep-room.

Midazolam• drugs given orally cannot be titrated accurately• hepatic metabolism• an overdose cannot be easily reversed• oral sedation requires cooperation from the child to ingest the

medication• Never re-dose• Per rectum - more reliable and controllable absorption, but

requires cooperation, bad compliance• Intranasal - whether the drug is absorbed directly from the

blood stream or there is direct uptake to the central nervous system, requires a higher level of training and monitoring

Midazolam• Intravenous sedation• requires a highly trained team• specialist anaesthetist• monitoring, adequate facilities and recovery options• controllable and may be readily reversible• inappropriate form of drug administration in extremely

anxious children• IV sedation - in a hospital environment or accredited dental

surgeries

Suitable procedures for midazolam sedation• Short procedures that require approximately 30 minutes duration.• Primary teeth extractions or up to two permanent molars.• 1–2 quadrants of restorative dentistry.• Short surgical procedures with good access in the mouth.not suitable for sedation• 3–4 quadrants of restorative dentistry• Extractions of permanent molars in each quadrant (invasive

procedure and bleeding from all four quadrants make airway management more difficult).

• Obese children• Parents who may not provide adequate care to the child

postoperatively.

Midazolam - complications• In rare cases, complications may occur in the form of so-called paradoxical

reactions (manifested as tearfulness, hyperactivity, agitation, refusal to aggressive behavior)

• or vomiting.

Symptoms of midazolam overdose can include:• Ataxia• Dysarthria• Nystagmus• Slurred speech• Somnolence (difficulty staying awake)• Mental confusion• Hypotension• Respiratory arrest• Vasomotor collapse

Discharge criteria after sedation

• Self-maintenance of airway.• Easily rousable and able to converse.• No ataxia, can walk properly.• Tolerating oral fl uids.• Discharge in the care of a responsible adult with appropriate

information about• after-hours contact if a problem arises.