6.pediatric Sedation

 

CHAPTER 6

Pediatric Sedation  Jeffrey D. Bennett, DMD  Jeffrey B. Dembo, DDS, MS Kevin J. But Butterf terfiel ield, d, DD DDS, S, MD

The anesthetic anesthetic management management of the pediatric patient presents the oral and maxillofacial surgeon with unique and different challenges from those with an adult

ity to the pharynx, thereb therebyy rendering the patient susceptible to airway obstruction and irritation. irritation. These factors factors can result in a significan significantt degree degree of hypo hypoxia. xia.1,2 Such

exchange. The pediatric exchange. pediatric trache tracheaa is also more compliant. The increased compliancy makes the airway susceptible to collapse secondary to increased negative

patient. The surgeon surgeon must be aware aware of  anatomic and physiologic differences, different pharmacokinetics pharmacokinetics and pharmacodyn co dynami amics cs of mos mostt medi medicat catio ions, ns, and the unique psychological development of  the child and his or her corresponding ability to cope with the stress of of the surgical experience. experience. As the the child child matures, matures, changes in these parameters parameters occur; therefore, an understanding understanding of the growth growth and maturation of the pediatric patient patient dicdictates the selection selection of the anesthetic techtechnique and medications used in the

effects can be exacerbated by a decreased minute ventilation and airway tone secondary to sedative medication used during the anesthetic administration. There are anatomic differences unique to the pediatric upper airway that increase increa se the risk of airway obstruction obstruction.. In the young child the tongue is large relative to the the size of the oral cavity cavity.. It is positioned higher in the oral cavity impinging on the soft palate secondary to the rostrally tra lly posit position ioned ed larynx larynx.. Ly Lymph mphoid oid hypertr hyp ertroph ophyy with enlarge enlargement ment of the

inspiratory pressur inspiratory pressure. e. This is signifi significant cant because beca use of of the pot potent ential ial for for airway  airway  obstruction in the nonintubated patient. When patients become obstructed they  attempt to overcome the obstruction by  increasing incre asing the the respiratory respiratory effort. effort. In the child an attempt to compensate for upper airway obstruction with increasing respiratory effort effort can cause collapse collapse of the trachea and bronchia bronchiall passages, which may  may  paradoxically worsen worsen the obstruction. obstruction. The frightened child may already be at risk for airway collapse since crying tends to

patient’s management.

Much of the uniqueness Much uniqueness regarding regarding anesthetic managem management ent of of childr children en in oral and maxillofacial surgery is focused on anesthesia delivered during intraoral procedures in which the patient is not intubated. bate d. Intr Intraora aorall surgery surgery in the anesanesthetized nonintubated patient presents a

tonsils and adenoids between the ages of  4 and 10 years can also contribute to upper airway obstruction. The low lower er airwa airwayy, co consi nsisti sting ng of of the trachea trac hea,, bro bronch nchi, i, and alveo alveoli, li, als also o differs differs between pediatric and adult patients. The trachea and bronchi are conduits in which gas is transported from the environment to the alveoli. The pediatric airway diameter is relative relatively ly smaller than than that of the adult. Since resistance resistance is inversely inversely proportionall to the radius tiona radius of the lumen lumen to the the fourth power, power, there is an increased resis-

increase negative inspiratory pressure. Anatomic differences between pediatric and adult patients diminish the efficacy of ven ventila tilation tion.. In the the child child each each rib is angled more horizontally relative to the vertebral column; column; adults’ adults’ribs ribs have a caudal caudal 3 slant. Additi Additionally onally,, the accessory accessory muscles are less developed developed in the child. This results results in a less effective thoracic expansion and a greater dependence on diaphragmatic breathing. breathi ng. Upper airway airway obstruction in the  young child occurrin occurringg with sedation can result in a paradoxic chest wall movement,

formidable formidab le and unique unique challeng challenge. e. The foremost concern is that the surgical site—the oral cavity—is in close proxim-

tance. Narr tance. Narrowing owing of the airway airway secondary  secondary  to secretions or edema will have a more profound adverse effect on airway 

characterized by an inward movement of  the chest opposing the expansile downward movemen movementt of the diaphragm. diaphragm. Great Greater er

Anatomic and Physiologic Considerations Respiratory Respir atory System

 

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energy is require energy required, d, whic which h can lead lead to fatigue and subsequent hypoxia. Exchange Exchan ge of gas takes place place within the alveoli alv eoli.. Clos Closing ing volume, volume, whic which h is the volume of the lung at at which dependent airairways begin to close, close, is greater in the pediatric patient. The increased closing closing volume

goscopy and goscopy and visualizati visualization on of the glottic glottic opening more difficult in the pediatric patient. Adenoidal hypertroph hypertrophyy can also result in hemorrhage or or obstruction of an endotracheal endotra cheal tube, particu particularly larly during nasal intubation. The narrowest narrowest part of of the trachea trachea in

The trachea is also shorter in the pediatric patien patient. t. It is not uncomm uncommon on that head position is frequently changed during an oral and maxillofacial surgery procedure; this can cause the the tube to become become displaced out of of the trachea or or pass further into the trachea and impinge on the

in the pediatric patient results in increased dead space ventilatio ventilation. n. Thus, more energy  must be expended to adequately ventilate the alveoli. The alveoli are are also both smaller and fewer in number in the pediatric patient than in the the adult. adult. The alveoli alveoli increase in number until around 8 years of  life and continue to increase in size until full adult growth growth is reached. reached. The number of alveoli may may increase more more than 10-fold 10-fold from infancy infancy to adulthood, with a resulresultant increase in surface area that can be as great as 60-fold.4–6

the pediatric patient is the cricoid cartilage, in contrast contrast with the glottis in the adult.. It is not adult not until until the the age of of appro approxiximately 10 to 12 years that the pediatric airwayy mature airwa maturess to to that that of of the adult adult.. In the pediatric patient care must be taken when placing and securing an endotracheal tube to prevent prevent impingement of of the tip of the tube on the narrow subglottic region. regio n. Suc Such h impinge impingement ment of the endo endo-tracheal tube on the tracheal mucosa can result in edema and tracheal narrowing causing increased airway resistance post

mucosa overlying the cricoid cartilage. Change Chan ge in head head position position,, use of an endoendotracheal tube that is is too large, and patient age between 1 and 4 years are three factors contributing to the reported 1% incidence of postintubation croup.16 Certain congenital anomalies are well recognized for their altered altered anatomy. anatomy. Some of the most commonly commonly encountered encountered disorders are Crouzon syndrome (hypoplastic maxilla—obl maxill a—obligate igate mouth breather), breather), Goldenhar’s syndrome (micrognathia, vertebral anomalies), hemifacial microsomia (hypo-

Functional residual capacity (FRC) is the volume volume of gas in the lung after after a normal expiration and is related to the surface fa ce are areaa of th thee lung lung.. Th Thee pedi pediat atric ric patient has a diminished FRC expressed on a basis basis of weight.7 This is illustrated by  a minute ventilation to FRC ratio of  approximately 5:1 in a 3 year old and 8:1 in a 5 year old compared to approximately 2:1 in an adult.7 FRC decreases further in the sedated patient. patient. The FRC provides provides 8 a pulmonary oxygen reserve. Because children have a higher metabolic demand

extubation. Unc Uncuffed uffed tubes are used by  most anesthesiologists for patients less than 8 to 10 years years of age.13 The arguments against cuffed tubes are that they  increase incre ase the the risk risk of of airwa airwayy mucosa mucosall injury and that an appropriately sized uncuffed endotracheal tube can provide an adequate seal at the level level of the cricoid cartilage. Formulas exist for calculating calculating the appropriate appropriate size of endotracheal tube ([age (yr) +16]/4) and the appropriate length leng th of endo endotrac tracheal heal insertio insertion n ([age 14 (yr)/2 + 12]). Howe weve verr, 28 28% % of th thee

plasia of mandib mandibular ular condyle condyle and ramus), ramus), Möbius sequence (micrognathia and limited mandibular movement), Pierre Robin’s Robin’s anomalad anomala d (micro (micrognathia, gnathia, glossopto glossoptosis), sis), and Treacher Collins syndrome (mandibular hypoplasia). hypoplasia). These craniofac craniofacial ial anomalies may complicate ventilation and/or endotra end otrache cheal al intubatio intubation. n. For example, example, maxillary or mandibular hypoplasia may  increase the difficulty in achieving a satisfactory fact ory mask fit. Anat Anatomic omic differenc differences es in the nasal cavity may impair nasal ventilation. tio n. This can pote potenti ntiate ate respi respirato ratory  ry 

and greater greater oxyg oxygen en consump consumption, tion, the decreased FRC results in a more rapid desaturation desaturat ion of hemoglobi hemoglobin n during periperi9–11 ods of resp respirat iratory ory depr depressio ession. n. One model comparing the child to the adult concluded conc luded that that an apneic period of of 41 seconds in the pediatric patient would result in an arterial oxyhemoglobin saturation rati on of 85%, com compare pared d with an apneic apneic 12 period of 84 seconds seconds in the adult. adult.

obstruction during an intraoral procedure in which a pharyngeal curtain is placed and the patient is dependent on nasal respiration. The tongue may may be displaced posteriposteriorly by either maxillary or mandibular hypoplasi hypo plasia, a, incr increasin easingg the potential potential for obstruction.

Endotracheal Intubation There are also anatomic differences between the pedi-

time the initially selected uncuffed endotracheal tube does not provide an adequate seal, and re-intubation re-intubation may be nec15 essary. An additional benefit in using the uncuffed tube is that a larger tube may be inserted, which causes less airway  airway  resistance and less breathing work. The argument for a cuffed endotracheal tube is that the fit can be adjusted and it can protect against aspiration. aspiration. Ensuring that the cuff pressure does does not exceed exceed 25 cm H2O, which is believed to be the mucosal mucosal capillary capil lary pressure, pressure, can minimize minimize injury 

atric and adult airways that influence intubation. batio n. A large large tongue tongue,, rost rostral ral larynx, larynx, and long and narrow epiglottis make laryn-

to the mucosa. mucosa. When using using an uncuffed tube tu be,, an air air lea leak k of 25 cm cm H2O should be allowed.

Cardiovascular Cardiovascu lar System The pediatric cardiovascular system has some significant differences compared with that that of the adult. adult. Each releva relevant nt physphysiologic difference is outlined below. Cardiac Output Perfusion is dependent on cardiac output and peripheral resis-

 

Pediatric Sedation

tance. Card tance. Cardiac iac output output is dependen dependentt on heart rate and stroke stroke volume. volume. The pediatric heart has less complianc compliancee than that of  the adult, adult, with minimal minimal ability ability to alter alter strok str okee volume volume.. Th Thus, us, pe pedia diatri tricc cardia cardiacc output is largely dependent on heart rate (Table 6-1). Neural Innervation The myocardium is innervated by both the sympathetic and parasympathetic parasympath etic nervous systems, systems, with the parasympathetic nervous system having a greater influence in the pediatric patient than in in the adult. adult. In one one retrospecti retrospective ve study the incidence incidence of bradyc bradycardia ardia during anesthesia was reported to be age related. The incidence incidence of bradyc bradycardia ardia was approxiapproximately threefold less in the 3- to 4-year-old compared with the 2- to 3-year-old. 17 Blood Pressure Blood pressure is the product of cardiac output and peripheral peripheral vascular vasc ular resistanc resistance. e. The pediatric pediatric patient patient has less ability to alter peripheral vascular resistance; resistanc e; therefore therefore,, blood pressure pressure is largely dependent dependent on cardiac cardiac output. output. A bradycardia with resultant decreased cardiac output thus results in a decrease in blood pressure since the child cannot compensate by increasing peripheral vascular resistance resistance..

Summary  These fundamental concepts clearly illustrate the increased potential risks associated with sedating the pediatric patient: •

The air The airwa wayy is is more more su susc scep epti tibl blee to to obstruction, and the the patient patient has has less ventilat vent ilatory ory reserve; reserve; thes thesee result in a more rapid oxygen desaturation (and hypoxia causes bradycardia).

•

•

The pedi The pediat atri ricc pati patien entt has has incr increa ease sed d parasympat paras ympatheti heticc innervation, innervation, resu resultlting in a more more rapid onset of bradycardia (which may be influenced indirectly by respiratory impairment or directly by the sedative drugs). There The re is les lesss card cardio iovas vascul cular ar co compe mpenn-

comprehend the need for or benefits comprehend benefits of the surgical procedure. procedure. Childr Children en > 6 years old or those who have better-developed social skills (eg, acquired from daycare programs) may be more capable capable of understa understanding nding the situation and expressing their concerns.18 If po poss ssib ible le,, an old older er chi child ld shou should ld be

satory ability, ability, which results results in hemodynamic instability.

allowed to participate in determining the anesthetic treatment and should be exposed to the various induction techniques niq ues:: in intra trave veno nous, us, in intra tramus muscul cular ar,, ora oral, l, and inhalation. Adolescents may be more capable of  comprehending the planned surgery and anesthet anes thetic ic mana manageme gement. nt. Ho Howev wever er,, they  are not adults. They have have the ability to demonstrate myriad behaviors and rapid mood changes. changes. A paradoxic paradoxic reaction reaction to sedation in which the adolescent appears to become agitated after the administra-

Preoperative Preoperati ve Evaluation Evaluation of the Patient The purpose of a preoperative preoperative evaluation evaluation is to compile information about the patient to establish the most optimal treatment plan. One needs needs to assess assess the psychological and behavioral development of  the patient, patient, obtain a medical medical history history that identifies both acute and chronic disease processes proc esses,, and determine determine the patient’ patient’ss preparation for surgery (eg, cardiovasc cardiovascular ular status), while performing an appropriate appropriate physical examination dictated largely by  the patient’s medical history.

tion of anxiolyti anxiolyticc medication medication may necessitate a deeper deeper level of anesthe anesthesia sia than than what may have originally been planned. Another concern in the adolescent patient is the the use of illicit substance substances. s. This has reached epidemic proportions with Psychological Assessment  an estimated estimated 10.8% of 12- to 17-year-old 17-year-old The perioperative period can be very   youths reported rep orted to be current illicit drug stressful for a child. The child is confrontconfrontusers in 2001.19 ed with an unfamiliar environme environment, nt, unfaThe presenc presencee of paren parents ts during during the miliar people, apprehen apprehension sion about the administratio admini stration n of the sedative sedative agent may  unkn un know own, n, an and d loss loss of co contr ntrol ol.. Th Thee child child reducee the stress reduc stress of the procedur proceduree and fearss separation fear separation from from the parents, parents, the improvee the child’ improv child’ss cooperation cooperation.. Conthre th reat at of ne need edle les, s, th thee per perce cept ptio ion n of  of  versely,, a parent’s parent’s anxiety may be sensed impendin impe ndingg pain, pain, and the fear of mut mutilaila- versely by the child, child, furth further er exacerbat exacerbating ing the tion. Younger children children frequently cannot 20 child’s child ’s own level level of anxie anxiety ty.. Cle Clear ar,, simverbalizee these concerns. Behavio verbaliz Behavioral ral maniple, and succinct explanations appropriate festation festa tionss of perio perioperati perative ve anxiety anxiety may  may  for the age of the child child may minim minimize ize include inc lude hyp hyperve erventi ntilati lation, on, trem tremblin bling, g, cryadverse behavior. ing, agit agitatio ation, n, and and/or /or physic physical al resistan resistance. ce. Children Childr en < 6 years of age frequently frequently cannot Preoperative Fasting 

Table 6-1 Mean Meanss and Ranges Ranges of No Normal rmal Cardio Cardiovascu vascular lar Funct Function ion  Age (yr) Function

Heart rate (beats/min) Syst stem emic ic ar artter eria iall pr pres essu surre (mm (mm Hg) Cardiac output (mL/kg/min)

2–6

7–13

14–18

100 (80–120) 75– 5–1115 15/5 /50– 0–775 150–170

90 (70–110) 95–1 95 –1225/ 5/60 60–8 –800 100–140

80 (55–95) 105 05–1 –1440/ 0/65 65–8 –855 90–115

The risk risk of pulmo pulmonary nary aspirat aspiration ion of gastric contents in the pediatric patient during anesthesia is reported to be up to 10 incidents per 10,000 cases.21–23 Morbidity secondary to aspiration includes obstruction from particulate material as well as aspiration pneumonitis that is dependent on both the quantity and

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acidity of the aspirate. acidity aspirate. Estab Establishi lishing ng parameters that minimize the risk of particulate gastric contents as well as decrease the quantity quantity and acidity acidity of residual gastric fluids can decrease the incidence of  this morbidity. Gastric emptying emptying of solids is variable. variable.

between the last food ingestion and the injury is the critical time period that is important in assessing a patient’s risk of  gastric aspiration. aspiration. Each patient and situation must must be assessed assessed indivi individually dually.. If  sedation or general anesthesia is required, patient management may necessitate the

chospasm,, seve chospasm severe re coughing, coughing, airwa airwayy hype hyperractivity acti vity,, brea breath th holdi holding, ng, dimin diminished ished diffusion capacity, capacity, increased closing volumes, volumes, atelectasis, and postintubation postintubation croup.31–34 The elevated hyperactivity with associated bronchoconstriction and the increased closing volume compounded by a greater

A 6- to 8-hour fast from solids is recommended to allow gastric emptying and minimizee the risk of minimiz of particulat particulatee aspiraaspiration. Altern Alternativel atively, y, gastric emptying time for clear liquids is approximately 10 to 15 minut minutes. es. Aft After er a 1-hou 1-hourr fast of of cle clear ar liquids, liqu ids, appr approxi oximat mately ely 80% of the co connsumed liquid is usually absorbed from the stomach stomach.. Num Numero erous us studies studies have shown sho wn that consump consumptio tion n of unli unlimite mited d volumes vol umes of cle clear ar liquids liquids by pediatri pediatricc patients up to 2 hours prior to surgery  does not significantly increase the quanti-

placement placeme nt of an endotra endotrache cheal al tube to to minimize the risk of gastric aspiration. aspiration. The following interventions may minimize the the risk of of aspir aspiratio ation n and/or and/or the ensuing injury that may result from gastric aspiration aspira tion:: an H2-antagonist such as cimetidine to decrease gastric gastric acidity, acidity, a clear antacid such as sodium citrate to decrease gastric acidity acidity,, and metoclo metoclopramide pramide to promote gastric emptying and increase the tone of the lower lower esophageal esophageal sphincter sphincter.. Glycopyrrolate also reduces the acidity  and an d volu volume me of of ga gastr stric ic con conte tent nts. s.29

oxygen uptake (secondary to the inflammatory mato ry response response of the infecti infection) on) and a decreased FRC (which normally occurs with general anesthesia) increases the risk  of hy hypo poxe xemi mia. a.35–42 Oxygen desaturation can occur both intraoperatively and postoperatively; the latter latter indicates indicates the need need for continued postoperative monitoring. URIs have also been demonstrated to cause respiratory muscle weakness that can persist for up to 12 days.43 The pathophysiologic changes that contribute to these adverse respiratory events can persist

ty of gastric volume volume or gastric acidity. acidity.24–28 Guidelines have thus been established for healthy pediatric patients that allow  unlimited unlimit ed amounts of of clear liquids liquids to be consumed up to 2 to 3 hours prior to surgery.. This recommendation surgery recommendation avoids the need for an extended extended fast, fast, which has has the potential to make the patient irritable and uncomfortable and to increase the incidence inciden ce of hypote hypotension nsion secon secondary dary to dehydra deh ydratio tion. n. Ho Howev wever er,, in most most cases cases it still may be simplest to state that the child should have nothing by mouth (NPO)

Atropine, alternativ Atropine, alternatively ely,, decreases the tone of the lower esophageal esophageal sphincter sphincter and predisposes to gastroesophageal reflux of  stomach contents.

It is not uncommon for children to present for surgery with a runny runny nose. nose. Reports of  of  children presenting to surgery with or having recently had such symptoms state incidences as high as 22.3% and 45.8%, respectively.30 Rhinitis is not a contraindication to general anesthesi anesthesia. a. Altern Alternativel atively, y, a child

for 4 to 6 weeks after the URI. Traditional office-based ambulatory  anesthesia in oral and maxillofacial surgery is dependent on spontaneous ventilation in the nonintubated nonintubated patient. This is significant since since the incidence incidence of adverse respiratory events is less in a patient anesthetized with a face mask or laryngeal mask airway than in those with an endotracheal trac heal tube. Ho Howeve weverr, surge surgery ry inv involvin olvingg the airway has been shown to increase the risk of adv advers ersee resp respirat iratory ory eve events nts.. Although intraoral surgery is not truly air-

after midnight and to schedule the procedure as the first case in the morning. Children who are scheduled in the afternoon may have a light breakfast at least 6 hours prior to the surgery.

Patients may present to the office or emergency room requiring urgent care. The injury or the patient’s ability to cooperate may be such that the necessary  treatment cannot be completed on the

with a severe upper respiratory infection (URI;; sympt (URI symptoms oms include include a produ productiv ctivee cough, fever fever,, and mucopurulent mucopurulent discharge) discharge) should not be anesthe anesthetized. tized. Howe However ver,, it is unclear whether a child with a mild URI or a child recovering from a URI should be anesthe ane sthetize tized; d; the theref refore ore,, it is important important to differentiate between the diagnosis of  rhinitis and an infective process. Pathophysiologic changes in the pulmonary system secondary to a URI include increased nasal and lower airway  secretio secr etions, ns, incr increase eased d airway edema edema and

way surgery, surgery, it encroaches encroaches on the airway  airway  and can cause airway irritability. irritability. The nonintubated patient undergoing oral or maxillofacial surgery is also susceptible to periods peri ods of hyp hypove oventil ntilatio ation n and apnea, apnea, which cannot be corrected without interrupting rupti ng the surgery. surgery. Kin Kinouc ouchi hi and colleagues demonstrated that a patient with an active or recent URI requires approximately 30% less apneic time to desaturate than does a healthy patient.44 In conclusion, conclusion, the patient patient who who presents for elective surgery with allergic

patient while he or she is awake and nonmedicated medic ated,, despi despite te the the fact that the patien pat ientt is not not NPO. NPO. The dura duratio tion n

inflammat inflam mation ion,, and inc increa reased sed airwa airway  y  tachy tac hykin kinins ins.. The These se pat pathop hophy hysio siologi logicc changes can result in laryngospasm, laryngospasm, bron-

rhinitis or a mild URI that is not not of acute onset may be anesthetized in the office witho wit hout ut an an endo endotra trach chea eall tube tube.. If th thee

Emergency Treatment: Full Stomach

Upper Respiratory Infection

 

Pediatric Sedation

patient has has a significant significant URI, URI, the proceprocedure should be rescheduled. rescheduled. Traditional guidelines suggest that the procedure should be rescheduled for 4 to 6 weeks laterr if the patien late patientt is to be intuba intubated, ted, but because many children have several URIs per year, year, trying to reschedule reschedule the surgery 

of age has been been reported reported to to be approxiapproxi46 mately 0.5%. Beca Because use of of the severi severity ty of  the potential consequences of anesthetizing a pregnant pregnant patient, it is important important to reliably detect a pregnancy. pregnancy. An accurate accurate and reliable history in the educated patient can be effective.47 How However ever,, many patien patients ts in

medical/dental staff, (3) the medical hismedical/dental tory of the patient, patient, (4) the patient patient’s ’s prior surgical or anesthetic anesthetic experience experience,, (5) the infringement infringem ent of the procedure procedure on the airway,, and (6) the way the duration duration of pro proced cedure ure.. The selected technique should ideally be painless, be accepted accepted by the patient patient and

for a date when the child is without w ithout symptoms may be difficult.45 Considering the above abo ve,, a dela delayy of of 2 week weekss is pr proba obably  bly  acceptable before performing a short office-based minor dentoalveolar procedure in which the patient is not intubated.

this age group may not provide an accurate history, histo ry, especi especially ally in the prese presence nce of of their family. This is not not an acceptable rationale rationale for ro routin utinee testi testing. ng. If rou routin tinee testi testing ng is is implemente implem ented, d, there is the the potential potential for a false-positi falsepositive ve test result, result, whic which h may have significant signific ant emotiona emotionall consequen consequences. ces. The issue remains controversial.

It is generally agreed that managing the anxious anx ious,, unc uncomf omforta ortable, ble, and unc uncoop ooperaerative pediatric pediatric patient patient is one one of the more more

parents, be rapid in onset, parents, onset, be appropriate appropriate in duration with rapid recovery, recovery, and have minimal side effects and a broad margin of safe safety ty.. If drug administ administrati ration on is associassociated with pain pain or adverse adverse memories, memories, the benefit of the sedation sedation may be decreased. decreased. The anesthetic must also provide an environment in which the procedure can be completed. comple ted. In certain clinical clinical situations a moderate mode rate degree degree of mov moveme ement nt may be acceptable, accep table, wherea whereass in other situations situations no movement moveme nt is accept acceptable. able. Also, the inducinduction agent may establish a depth such that

ing child childhoo hood. d. The cause cause of thes thesee murmurmurs is usually turbulent blood flow  through any of the great great vessels. vessels. Featur Features es that commonly identify innocent murmurs include those that are crescendodecrescendo decres cendo and of short duration duration and low intensity intensity,, and those that occur early  early  in systole. systole. All diasto diastolic lic murmurs murmurs are pathologic. patholo gic. The patient’s patient’s history may also suggest signs and and symptoms symptoms of cardiac pathology patho logy.. These may may include include limited limited exerc ex ercise ise tol toleran erance, ce, pale col color or,, freq frequent uent respira res piratory tory problems, problems, hypo hypoxe xemia, mia, palp palpii-

difficult anesth difficult anesthetic etic tasks. tasks. The primary  primary  goals in the management management of the pediatric pediatric patient include reducing anxiety, anxiety, establishing coope cooperation, ration, ensuring comfo comfort, rt, establishing amnesia amnesia and analgesia, analgesia, and ensuring hemodynamic hemodynamic stability stability.. Although the the goals of sedation are similar similar for both the the child and the adult, reducin reducingg anxiety in the adult may enhance cooperation, whereas in the child it may not. To achieve a satisfactory result and facilitate facilitate completion completion of the planned surgical surgical procedure, procedure, the child may  requiree a greater depth of requir of sedatio sedation. n.

the treatment treatment may be complete completed, d, but in otherr cases othe cases the goal goal of the induct induction ion agent may be to establish sufficient sedation to allow intravenous access and mainten main tenanc ancee of anes anesthes thesia ia with intraintraveno ve nous us ag agen ents ts.. La Last stly ly,, an and d of ex extr trem emee importance import ance,, one is cautio cautioned ned not not to sedate a young child who will be transported in a car seat prior to arrival in the office.. The respiratory office respiratory depressant depressant effect of the medica medication tion combi combined ned with with the positioning position ing of the unattended unattended child in the car can result in unrecognized upper air-

tations, or dysrhythmias. tations, dysrhythmias. A murmur in an asymptomatic child is frequently not patholo path ologic, gic, and no special special anesthe anesthetic tic consideration consi derationss are requir required. ed. How However ever,, if  there is uncertainty regarding the significance of a murmur, murmur, a consultatio consultation n with a cardi ca rdiolo ologis gistt is rec recomm ommen ended ded.. Fo Forr patients with congenital heart disease, prophylaxis against bacterial endocarditis is necessary.

way obstruction or respiratory impairment, with resultant resultant death or significant significant 48 neurologic impairment.

Pregnancy Testing in the Adolescent Patient 

Sedation should be accomplished in as nonthreatening a manner as possible. Because some children may be intensely  afraid afr aid of nee needle dles, s, est establ ablish ishing ing int intraravenous access access may may not be possible. possible. The surgeon must be familiar with alternative techniques that allow for a safe satisfactory induction and recovery from anesthesia. Each case case must be consider considered ed individually to select both the most appropriate appropria te drug and the route of administration istra tion.. The surgeon surgeon must must take take into consideration the following factors in

The inciden incidence ce of pregna pregnancy ncy detected detected by  by  routine universal testing in the ambulatory  surgical adolescent between 12 and 21 years

developing the anesthe developing anesthetic tic plan: plan: (1) the age of of the patien patient, t, (2) the the level level of anxi anxiety  ety  and ability to cooperate with

venous access. access. A percentage percentage of children do not cooperate and allow an intravenous catheter cathe ter to be inserte inserted. d. Man Manyy children children

Cardiovascular Cardiovascu lar Evaluation The child who presents for surgery with a previously undiagnosed cardiac murmur poses a diagnostic diagnostic challen challenge. ge. Innoc Innocent ent murmurs are are heard in up to 50% of of normal pediatric patients at some point dur-

Sedative Techniques

Routes of Administr Administration ation Sedative medication may be administered by many many routes, routes, including oral, intranasal, tran tr ansm smuc uco osa sal, l, rec ecta tal, l, in intr traamu musc scul ular ar,, inhala inh alatio tional nal,, and int intrav raveno enous. us.49 The advantage of the intravenous intravenous route is that it results in the most rapid onset, onset, rapid offset, and predicta predictable ble effect. effect. The disadva disadvanntage is that it entails establishing intra-

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report the needle puncture from either intravenous placement or intramuscular injection as as the worst part part of their care. Even with a cooperative or an anesthetized thet ized child, child, gaini gaining ng peripheral peripheral intravenous access can present a challenge. Proper Pro per knowledg knowledgee of ven venous ous anatom anatomy  y 

Tibial tuberosity

with a controlled organized approach gives the best chance chance for success. Commonly accepted sites for venous cannulation include include the the dorsum of the hand, hand, volar aspect asp ect of the wrist, wrist, ant antec ecubi ubital tal fossa fossa,, an and d greater great er saphenous saphenous vein. vein. Eve Even n when an an alternativee route (eg, inhalation or intraalternativ muscular) is used to induce the anesthetic, we recommend recommend the establishment establishment of intravenous access. access. This can be achieved achieved once once the child child is sedated. sedated. Eve Even n if the procedur proceduree can be accomplished without the administration trati on of an intraven intravenous ous agent, agent, an estabestablished intravenous line can be used to administer intravenous intravenous agents ifif needed to augment the initial anesthetic agent or to prolong prol ong the duratio duration n of the anesthe anesthesia. sia. The line can additionally be used to administer other medications required to manage adverse events. In an emerge emergent nt situatio situation, n, if the traditraditional peripheral cannulation technique is not successful, successful, the clinician has has two possible access sites that allow for a high degree of pr pred edic icta tabi bili lity ty.. Th Thes esee site sitess are are the the femoral vein and intraosseous access,

6-1 For intraosseous infusions a bone marrow needle or specially made intraosseous needle is inserted into the tibial plateau (just (just medial and down from the tibial tuberosity). tuberosity). The catheter is then secured and intravenous solutions and medications may be administered. Adapted from American American Heart   Association. Textbook of pediatric advanced advanced life support. Dallas: American American Heart Heart Association; Association; 1994.

reached. The depth of the needle insertion should shoul d be plan planned. ned. If it is advan advanced ced too far,, the needle far needle penetrate penetratess the posterior posterior cortex and and does not allow allow infusion. infusion. The needle should be firmly set in the bone. Often bone marrow may be aspirated to confirm the placement. placement. A syringe or intra-

a mixture of oxyge oxygen n (minimum concentraconcentration of 30%) and nitrous nitrous oxide using using a full face mask. Inducti Induction on can be achieved using one of of two tech techniq niques. ues. The poten potentt vapor vapor agent can be increased gradually every few  breaths until the induction is complete. Alternativel Altern atively, y, the patient may be immedi-

which are associated with a higher incidence of morbidity morbidity.. The femoral femoral vein vein usually requires a 20-gauge or 22-gauge angiocatheter. angiocathete r. The intraosseous intraosseous needle is recommended primarily for children < 6 years of of age because they they still have have red bone marrow   (Figure 6-1). In this technique a bone marrow needle needle or a no. no. 14 through 18 Cook intraosseous infusion needle is percutaneously inserted into the flat portion portion of the proximal proximal tibia. tibia. Entry is made in the tibial plateau 1.5 cm below the knee joint and 2 cm medial to the tibial

venous line can venous can be attached; attached; if it runs easeasily, placement is confirmed. confirmed. Slight extravaextravasation around the placement site should not pre preve vent nt the the use of the nee needle dle.. Th Thee catheter can serve as a conduit for all intravenous intraveno us fluids and drugs. The inhalational inhalational induction induction of anesthe anesthe-sia with a potent anesthetic agent also provides rapid rapid onset, onset, rapid offse offset, t, and a prepredictab dic table le eff effect ect.. Th Thee adva advanta ntage ge of thi thiss technique, similar to the intravenous route, is the option to use short-acting agents enabling the anesthetic state to be rapidly 

ately administered a high concentration of  the potent inhalational inhalational agent. A modification of the latter latter technique technique is to to ask the patient to exhale completely and then take a deep inspiration inspiration of the vapor agent agent and hold his or or her breath. breath. Inducti Induction on will be achieved achiev ed with a single breath, and spontaneous ventilation will resume once a state of general anesthe anesthesia sia is achiev achieved. ed. For brief  proced pro cedures ures (eg, (eg, extr extracti action on of a deciduous deciduous tooth),, once general anesthesia tooth) anesthesia is achiev achieved, ed, the face mask can be removed, removed, the proceprocedure performed, performed, the face mask mask reapplied, reapplied,

tuberosity.. The special tuberosity special bone bone marrowmarrowstiletted needle is inserted with a rotary  motion into the bone until the cavity is

terminated at the end of the procedure. terminated procedure. The traditional inhalation induction is accomplished by administering oxygen or

and the patient allowed to awaken breathing 100% oxygen. oxygen. Some clinicians advocate maintaining the general anesthesia by con-

FIGURE

 

Pediatric Sedation

tinuing the administrat tinuing administration ion of the potent potent vapor agent via a traditional nasal hood. This can result result in the delivery delivery of a diluted concentratio conc entration n of anesthe anesthetic tic agent agent to the the alveol alv eoli, i, res resulti ulting ng in a light lighteni ening ng of the patient’s patient ’s anesthetic anesthetic depth. Such an occurrence would necessitate the interruption of 

istration. Its primary disadvantage disadvantage is is the discomfort associated with the injection. Howeve Ho weverr, for the the uncoope uncooperativ rativee child, child, it may be the least traumatic method of  induci ind ucing ng anes anesthe thesia sia.. Fou Fourr anato anatomic mic regions are used for intramuscular administration istra tion of drugs: the delt deltoid oid musc muscle, le, the

administration can be inadvertently aspirated by the crying child. Bro Bronchia nchiall absorption can result in an excessive plasma level level of drug. The intranasal route was initially proposed for pediatric sedation because it was felt to to avoid avoid first-pa first-pass ss degradation degradation,, be

the procedure to replace the full face mask  to increase the alveolar concentration of  the inhalational inhalational agent. Althou Although gh the continued administrat administration ion of the vapor agent via a nasal hood is not contraindic contraindicated, ated, it may result in excessive environmental pollution,, even with a scavenger lution scavenger device that is a compon component ent of the nasal nasal hood. hood. A circuit circuit that scavenges the vapor agent must also be used with the face face mask. To avoid these these potential poten tial problems, problems, especial especially ly for longer longer proc pr ocedu edure res, s, the est establ ablish ishmen mentt of int intraravenous ven ous acc access ess is reco recommen mmended. ded. The

vastus lateralis muscle, the ventroglut ventrogluteal eal area,, and the superio area superiorr lateral lateral aspect aspect of the gluteus maximus muscle. muscle. These sites have have been identified because they have minimal numbers of nerves and large blood vessels, as well as adequate bulk to accommodate the volume volume of the injecte injected d medication medication.. The rapidity rapidity of onse onsett of the drug is dependependent upon upon the perfusion perfusion of the muscle. muscle. Absorption and onset are also affected by  the ionization ionization of the drug and the the vehicle in which it is dissolved. Oral administration is considered by 

rapid in onset, and be less traumatic traumatic than the other routes that possessed these same benefits.52 Medications administered intranasally do result in a rapid rise in the plasmaa level of a drug. This occurs plasm occurs because because the nasal cavity, cavity, which functions functions to warm and cleanse nasal respirations, respirations, has a relatively extensive surface area with a thin nasal mucosa mucosa and an an abundance abundance of capillaries that facilitate facilitate the absorption absorption of drug. The nasal mucosa also provides a direct connection to the central nervous system (CNS) through the the cribriform plate. Med-

vasodilatory effects vasodilatory effects of the potent potent agent may optimize conditions for establishing intravenous intrav enous access. access. Once access access is set, anesthetic depth can be maintained with intravenous anesthetic agents. There are a few disadvantages to inhalation induction.The induction. The vapor agent has a scent that may be objectionable to some. Applying Appl ying a scent scent (eg, scent scented ed lip gloss) gloss) selected by the child to the face mask may  alterr the odor alte odor of the agent. agent. The odor odor may  may  also be minim minimized ized if the child child breathes breathes through the nose as opposed to the

many to be the least-threatening induction technique. Children are generally familiar with and readily accept oral medications. Oral administration also is generally well accepted by the mentally impaired or autistic patient. patient. How However ever,, oral techniqu techniques es have have limit li mitati ation ons. s. In on onee stud studyy of of ch chil ildr dren en between betwe en the age age of 20 and 48 months months,, onethird of the children required that the medication be administered into the back of  their throat with a needle-free syringe.50 Although frequently used as a sole sedative agent by many many surgeons, surgeons, an oral sedative sedative

ication may be absorbed through the cribriform plate directly into the CNS through the capillary beds or the olfactory neurons, ron s, or directly directly into the cerebro cerebrospina spinall 53 fluid. Rhinitis or a URI may impair the absorption of a drug via this route.54 The intranasal intranasal route, route, although initially  initially  felt to be less traumatic than alternative routes, rout es, is frequently frequently not well accepted accepted by  55,56 children. The vol volume ume of medi medicat cation ion used frequently results in a portion passing into the pharynx and being swallowed. Therefore, There fore, the unpleasant unpleasant taste taste of the med-

mouth.18 In addition, inhalation induction is also dependent on the child accepting the face mask. Techniques such as asking the child to inflate a balloon may be employed to distract distract the child. child. Any need need for mild mild restraint should be explained to the parent and may be used to facilitate induction in the younger younger child. child. How However ever,, in older chilchildren or extremely uncooperative children, the technique is dependent on the child’s acce ac cept ptan ance ce of th thee face face mask. mask. If ex exce cess ssiv ivee physical restraint is necessary, necessary, an alternative technique should be considered.

agent can be used as a premedicant prior to establishing intravenous access or inducing general anesthesia by a different route (eg, inhalation inhal ation or intramuscular) intramuscular).. The limited volume of fluid administered with the oral medication is not associated with an increased risk for aspiration pneumonitis.51 The prima primary ry disadvan disadvantag tages es of oral sedation sedati on are are the the slow slow onset, onset, variabl variablee response resp onse,, and prolonged prolonged recovery recovery.. Inj Injectecting a sedative sedative agent agent into the back of the throat with a needle-free syringe (when the child does not otherwise accept the

ication is not avoided, and the drug is sub ject to first-p first-pass ass hepatic hepatic degradat degradation. ion. Midazolam is the most commonly intranasally  administered medication, but the acidic pH is irritating to the nasal mucosa. Transmucosal absorption has also been considered. considered. The oral oral epithelium epithelium is thin with a rich vascular vascular supply. supply. The minimum epidermal barrier and the vascular supply provide an environment that promotes relatively relatively rapid absorption absorption of drugs. Oral transmu transmucosal cosal admini administration stration of a drug also has has the advantage advantage of avo avoidin idingg

The intramuscular route of administration approximates approximates the rapidity and predictabili dict ability ty of onse onsett of intra intraveno venous us admin-

medication) has also been associated with adverse consequenc consequences. es. It has been theotheorized that the drug intended for orogastric

hepatic first-pass degradation. Transmucosal administration requires cooperation of the patient to keep keep the drug in contact contact

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with the oral mucosa. The medication may  may  be administered as a solution placed sublingually or as a lozenge. lozenge. At the present present time the only available lozenge that has an acceptable flavor and is commercially  available is fentanyl fentanyl citrate. Other sedative medications are are bitter. bitter. Palatabil Palatability ity can be

drug within the rectum. rectum. Howeve However, r, there are significant anastomoses between the three rectal veins, veins, and peak drug blood blood level has not clearly been shown to be dependent on the location location of agent deposition deposition within the rectum. Solutions are are absorbed more rapidly than are supposit suppositorie ories. s. A more dilute dilute

thalamoneocortical and limbic systems, which disrupts the brain from interpreting visual, auditory auditory,, and painful stimuli.61 The analgesic effect, effect, which occurs occurs at subanessubanesthesia plasma plasma levels, levels, is partially mediated by ketamine binding to the µ-opioid and NMDA NMD A recep receptors. tors. This is signific significant ant

improved by mixing these medications with a flavored solution that increases their volume; volume; thus, the solution solution will be bitter or the volume will be excessive, excessive, neither of which is advantageous advantageous for the transmucosal administration of a liquid/solution. liquid/solution. Man Ma ny, if no nott most most,, pe pedi diat atri ricc pati patien ents ts expectorate the medication or prematurely swallow the liquid medication that is placed within the oral cavity as opposed to keeping it there. Rectal drug administration has been used for the administra administration tion of antie antiemetmet-

solution with greater volume provides more rapid onset and prolonged duration.59 Stool within the rectal vault as well as expulsion of  an unmeasurable quantity of drug results in delayed or decreased decreased absorption. Alteration in the integrity integrity of the mucosa mucosa or the prespresence of hemor hemorrhoid rhoidss results results in great greater er absorption absor ption.. If a child is uncoopera uncooperative tive,, he or she may tightly close the anal sphincter during any any aspect aspect of the admin administ istrati ration on process. Excessi Excessive ve force both both in placing or removing the catheter may result in a laceration atio n of the mucosa mucosa and cause cause a greater greater

because the effect persists into the postoperative period and may decrease the need for postoperative analgesia.62 Ketamine is also unique in its effects on the respiratory respiratory system. In clinical clinical doses commonly used in oral and maxillofacial surgery,, ketami surgery ketamine ne usually preserves preserves upper airway musculature musculature tone, spontane spontaneous ous respiratio pira tions, ns, and FRC FRC.. Thi Thiss mini minimize mizess the the incidence inciden ce of upper airway obstruction obstruction and hypopneas/apne hypopne as/apneas, as, and maintains the pulmonary oxygen reserve.63,64 In contrast, most other anesthetics contribute to a

ics, ant ics, antipy ipyret retics ics,, and anal analges gesics ics to to both both adults and pediatric patients. Many sedative drugs that are usually administered IV,, IM, or orally can be administe IV administered red rectally.. Rect tally Rectal al administratio administration n may also be used in the management management of emerg emergencie encies. s. For example example,, recta rectall administrat administration ion of  diazepam is an acceptable route for the treatment treat ment of seizur seizures. es.57,58 The rectum is a flat organ that is usually empty empty.. Its blood blood supply supply is derived derived from the inferior rectal arteries and is drained via the superior, middle, and infeinfe-

absorption absor ption of drug.

decrease in muscular tone, respirat decrease respirations, ions, and FRC. In addition to maintaining maintaining upper airway muscular muscular tone, tone, ketami ketamine ne tends to to better maintain the pharyngeal and laryngeal airway reflexes. reflexes. This allows the patient to maintain the ability to swallow and cough, cou gh, whic which h minimi minimizes zes the risk of pulmonary aspiration. aspiration. Keta Ketamine mine has also been shown to relax bronchial smooth muscle and cause bronchial bronchial dilatation. dilatation. It has been used in the management management of wheezin wheezingg dur65 ing anesthesia. Despite these benefits the practitioner

rior rectal veins. The superior rectal rectal vein drains into the hepatic portal circulation via the inferior mesenteric mesenteric vein. The middle and inferior rectal veins drain into the internal iliac iliac vein. The internal internal iliac vein vein drains into the vena cava, cava, thus bypassing the hepatic-portal circulation and avoiding first-pass metabolism by the liver. The absorption of a drug that is adminadministered per rectum is affected by several factors.. The variab tors variable le abso absorptio rption n of of the drug may be partially influenced by the venous drai dr aina nage ge of th thee rectu rectum. m. Th Ther eref efor ore, e, so some me

feel to be the most appropriate anesthetic agents and the routes by which they  should be delivered. Ketamine Ketamine is a pharmacologic agent that induces a distinct anesthetic state that resembles resembles catalepsy. catalepsy. The patient appears awake but is noncommunicative. Nonpurposeful movements may occur but are not disruptive. The eyes are commonly  commonly  open with a blank stare and intact corneal and light reflexes.60 A lateral nystagmus is also very characte characteristi ristic. c. Ke Ketami tamine ne also

must respect the inherent dangers associated with the anesthetic management management of a patient. Respirato Respiratory ry depression charactercharacterized by a decrease in respiratory rate and tidal volume can occur with ketamine. Respiratory arrest has been reported in a 4-year-old child following the intramuscular muscu lar admini administratio stration n of keta ketamine mine 66 4 mg/kg. Ho Howeve wever, r, resp respirat iratory ory depr depresession is not common, and the occurrence occurrence of  apnea is more likely to occur in infants or with the rapid intravenous intravenous infusion infusion of an induction dose greater greater than 2 mg/kg. mg/kg. Slow 

individuals feel that absorption and subsequentt peak plasma quen plasma level level of medic medicatio ation n is dependent on the location location of deposition of  of 

produces amnesia and analgesia. The clinical effect created by ketamine results from a dissociation between the

intravenous infusion over 30 to 60 seconds of doses between between 0.5 mg/kg and 1 mg/kg should minimize minimize the incidence of signifi-

Pharmacologic Agents The objective in selecting a pharmacologic agent is to choose an agent that establishes an appropriate environment to complete the surgical procedure. procedure. The effects sought in the pediatric patient include anxiolysis, amnesi amn esia, a, ana analge lgesia sia,, imm immobi obiliz lizati ation, on, sed sedaation,, and hypn tion hypnosis. osis. Ther Theree are are numero numerous us agents that are currently used by oral and maxillofacial surgeons and other practitioners. In this section section we discuss what what we

 

Pediatric Sedation

cant respiratory respiratory depression. depression. Aspiration of  gastric contents can also occur despite the fact that ketamine better preserves the protective airway reflexes allowing a patient the ability to swallow and cough.67,68 The protective reflexes, although less impaired than with other

The adva The advanta ntage ge of int intram ramusc uscula ularr administration is that it does not require patient pati ent cooperat cooperation. ion. The mild distress distress associated associa ted with the injection injection is brief as the drug has a rapid onset, onset, within 3 to 5 minutes.. Dosi utes Dosing ng recom recommenda mendation tionss up to 10 mg/kg IM have been described in vari-

tration of a benzodiazepine benzodiazepine with ketamine ketamine 75 may prolong recovery. Midazolam produces a better reduction in unpleasant dreams than does diazepam.76 The favorable pharmacokinetic pharmacokineticss of midazol midazolam am compared with diazepam also provide a more rapid recovery. recovery. In a prospective investigainvestiga-

drugs, ar drugs, aree dimini diminishe shed. d. We feel feel that that a patient who is considered not to have an empty stomach should should not be sedated, and disagree with those who feel that preservation of the airway reflexes reflexes justifies sedating sedating 69 such patients. The pres preservati ervation on of the laryngeal reflexes is a protective mechanism; this may also contribute contribute to airway  complicat comp lications. ions. Ke Ketamin taminee produce producess an increase in salivary and tracheobronchial secre sec retio tions, ns, and the pre preser servat vation ion of the laryngeal reflexes may predispose the patient to laryngospasm.

ous papers and texts. The larger dose clearclearly produces produces a general anesthetic anesthetic state. For office-based or emergency-department procedures performed by oral and maxillofacia fa ciall surge surgeon ons, s, ho howev wever er,, a dose dose of of 4 to 5 mg/kg IM should provide effective dissociation. ciati on. One investiga investigation tion prospecti prospectively  vely  assessed pediatric patients requiring sedation for minor procedures in an emergency  department and found that a 4 mg/kg dose provided effective sedation and immobilization for 86.1% 86.1% of the children children.. A satissatisfactory quality of sedation was achieve achieved d

tion, ketami ketamine ne 3 mg/kg mg/kg with midazol midazolam am 0.5 mg/kg was administered to pediatric patients requiring sedation for minor surgical procedures in the emergency department.77 Although 30% 30% of the patients patients who received this regimen manifested “intermittent crying,” only 14% required required additional medication to establish a satisfactory  anesthetic anesthet ic state to allow completion completion of the planned treatment. treatment. Reco Recovery very for this regimen was at times prolonged. The level of sedation and and immobilizaimmobilization is dependent on the planned proce-

Ketamine has both direct and indirect effects on the cardiovasculature. cardiovasculature. The direct myocardial depressant effects are generally  not seen in the healthy patient anesthetized in the office. office. The indirect indirect effects, which are a result result of of a sympathetic sympathetic stimulat stimulation, ion, produce an increase in heart rate and blood pressure. pressur e. The former may may be more comcommon in the pediatric pediatric patient. These effects effects are well tolerated in the healthy pediatric patient.. These hemodynamic patient hemodynamic changes may  be reduced when ketamine is combined with an anesthetic agent that tends to blunt

with adjunctive local anesthesia for 97.2% of thes thesee patients, patients, alth although ough 3.7% 3.7% required required mild restraint despite adequate sedation and an absent withdrawal response to pain. Only 2.8% of the patients required required a repeat dose secondary to inadequate sedation.73 Local anesthesia is an important component of any sedative sedative technique technique used by oral and maxillofacial maxillofacial surgeons. surgeons. Althou Although gh this study demonstrated that it is not always required, require d, incorpo incorporation ration of local anesthe anesthesia sia into the anesthetic plan minimizes the amount amo unt of oth other er ane anesth stheti eticc agen agents ts

dure. Although the intent intent is to provide an atraumati atrau maticc experienc experiencee for the child, child, a mildly dissociative sedative and analgesic state compared with a deeper dissociative anesthetic state may be acceptable for a brief dent dentoalv oalveola eolarr procedure procedure.. The intent intent is to modify the patient’s patient’s perception perception of the procedure.. In this situation procedure situation the patient is is not profoundly sedated and the practitioner has to tolerate some movement and possibly possi bly some vocaliza vocalization tion.. Ke Ketamin taminee 2 mg/kg to 3 mg/kg IM should provide this desirable sedative depth. depth. The lower dose dose of 

sympathetic sympathet ic stimulat stimulation ion (eg, (eg, benz benzodiodiazepines, azepin es, propof propofol). ol). A disadvantage of of ketamine is is its stimulation lat ion of of dre dreams ams and and hallu hallucin cinati ations ons described desc ribed as “out “out of body body”” expe experienc riences, es, sensations sati ons of floa floating,and ting,and delir delirium. ium.70 Although the incidence is less in children < 16 years of  age, the inciden incidence ce may may be as as high as 71,72 10%. Ketamine is also contraindicated in patients who may have a globe or intracranial injury as ketamine increases both intraocular and intracranial pressure. Ketamine Ketami ne can be administere administered d IV, IV, IM,

required. The working time achieved required. achieved from a 4 mg/kg mg/kg dose of ketami ketamine ne was 15 to 30 minutes. minutes. A disadvantage disadvantage of intramusc intramuscuular ketamine is that recovery is variable and can be quite long. Although the mean mean recovery time in the above study was 82 minutes, reco recovery very from injection injection to discharge at times took up to 3 hours. Benzodiazepines can be administered concomitantly with ketamine. The purpose for coadministering a benzodiazepine is to reduce the the amount of of ketami ketamine ne adminisadministered, ter ed, redu reduce ce the the inciden incidence ce of ket ketamin aminee-

2 mg/kg is advantageous in that recovery  from injection to discharge approximates 60 minutes. minutes. For many many children children the low  low  intramuscular dose dose of ketamine provides a depth of sedat sedation ion that that allows allows the placeplacement of an intra intraven venous ous line line.. If nec necessary essary,, the depth of of sedation can can then be modified using intravenous intravenous medications. Incremental doses doses of ketamine 5 to 10 10 mg IV can be administered to the sedated patient, with onset occurring within 30 to 60 seconds. The durat duration ion of seda sedation tion is 10 10 to to 15 minutes. Although we have have found that

orally, intranasally orally, intranasally,, and rectally. rectally. We discuss only the intrav intravenou enous, s, intra intramusc muscular ular,, and oral administrations administrations of ketamine.

induced hallucinations, induced hallucinations, attenu attenuate ate the cardiov di ovas ascu cula larr eff effec ects ts of ke keta tami mine ne,, an and d 74 provide additional amnesia. Coadminis-

ketamine 2 mg/kg generally facilitates intravenous intraveno us placement, placement, one study reported that 31% of of the children children resisted resisted intra-

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venous plac venous placeme ement nt with with a dose dose of 3 78 mg/kg. For the patient who remains combative and for whom intravenous access cannot cannot be established, an additional dose of ketamine 1 to 2 mg/kg IM can can be administered. administer ed. If the child child allows placeme placement nt of an intravenou intravenouss catheter catheter (without (without any  any 

3 to 10 mg/kg, a more consisten consistentt effect is achieved achie ved with doses > 6 mg/kg. In one one investigation oral ketamine 6 mg/kg was administered for sedating anxious pediatric dental patients with a mean duration of  sedatio seda tion n of 36 minute minutes. s.84 The quality of  sedation was reported as good for 65% of 

of strat strategies egies to ensur ensuree that the full full oral dose is taken. taken. Atropine or glycopyrrolate glycopyrrolate can be orally administered with ketamine; however, howeve r, the time to peak decrease in salivation is 2 hours.91 Regardles Rega rdlesss of the route route of admin administraistration, ketamin ketaminee can establish a clinical clinical

premedican premedi cant), t), a dose dose of ket ketami amine ne 0.5 0.5 to 1 mg/kg IV administered over 30 to 60 seconds will establish dissociation. An anticholi anticholinergic nergic agent agent (eg, glyco glyco-pyrrolate or atropine) is frequently coadministered with ketamine to decrease hypersalivation. Tachycardia and postoperative psychomimetic effects are problems associated associated with ketami ketamine. ne. Atro Atropine, pine, when combined combined with ketami ketamine, ne, produce producess a significantly higher heart rate compared with the effect effect of glyco glycopyrrolat pyrrolate. e. As a tertertiary amine, atropin atropinee crosses the the blood-

the patients, patients, and 100% of the treatment treatment was effect described as a “chemical straightcomplet com pleted. ed. Mea Mean n reco recovery very time time was was  jacket.” The catatonic state created by ket56 minutes with one child sleeping for amine is different from that with other 3 hours. Crea Creating ting a state state of deep sedation sedation is gene general ral anesthetic anesthetic agents; ket ketamin amine, e, when dependent on using larger doses of medica- used at the doses discussed discussed above, may not tions. Ketamine 10 mg/kg PO was used as as a be considered to be a true general anespremedican preme dicantt in the management management of pedi- thetic. Howeve However, r, the anesthetic depth creatric patients undergoing invasive oncolog- ated by ketamine is not consistent with ic proc procedure edures. s. Appr Approxim oximately ately 50% of the conscio conscious us sedation, sedation, and airway airway probl problems ems patients were unresponsive at 60 minutes. can occ occur ur.. Ther Therefor efore, e, appr appropria opriate te anes anes-This dose was was ineffectiv ineffectivee in < 10% of the thetic standards for deep sedation or gen85 patients. Re Reco cove very ry,, ho howe weve verr, gen genera erally  lly  eral anesthesia must be followed. took 2 to to 4 hours, with 20% of of the patients patients

brain barri brain barrier er and can can,, its itself elf,, pro produc ducee postopera post operativ tivee delirium. delirium. A higher inciincidence of adverse emergen emergence ce phenome phenome-non, howev however, er, was not identifi identified ed in studstudies comparing glycopyrrolate with atropine.79,80 Both drugs can be mixed in the same syringe with ketamine for an intramuscular intramusc ular injection. injection. The peak effect effect of intramuscu intramuscular lar glycop glycopyrrolate yrrolate occurs within 30 minutes, minutes, at which time the procedure is frequently completed and the patient is in in the recovery recovery phase phase of treatment. If an intravenous intravenous line line is to be estab-

being deeply sedated at 120 minutes post administration. Several authors have have shown that the anxiolytic and sedative properties of midazo midazolam lam 0.5 mg/kg mg/kg result result in a more clinically effective sedation than does ketamine 5 or 6 mg/kg.86,87 The combinat combination ion of of oral midazola midazolam m and ketamine ketamine has also been described. This drug combination may provide effective sedation when oral midazolam has been ineffective. ineffec tive. One study that demonstrated demonstrated a greater efficacy with this combination used ketamine 4 mg/kg with midazolam

Midazolam Midazolam is a water-soluble short-actin shortactingg benzodiazepine benzodiazepine.. As a class of  agents, the benzodiazepines provide anxiol ysis, sedati sedation, on, and amnesia amnesia.. Midaz Midazolam olam can can be admini administere stered d IV IV,, IM, orally orally,, sublin sublingually gually,, intranasall intran asally, y, or rectally rectally.. Becau Because se of its water water solubility solubi lity,, intram intramuscula uscularr injec injection tion of midazolam is pain pain free, and absorption absorption is predict di ctab able le.. Unl nlik ikee ketam ketamin ine, e, ho howe weve verr, as a single agent there is no unique anesthetic benefit to the intramuscular administration of mida midazol zolam. am. Intranasal administration of midazo-

lished after lished after the onset onset of seda sedatio tion, n, glyc glycoopyrrolate can be administered IV with a peak effect in approximately 1 minute. The dose of atropin atropinee is 0.1 to 0.2 mg/kg, mg/kg, with a minim minimum um dose dose of 0.1 mg and and a maximum dose of 0.6 mg. Glyc Glycopyrrol opyrrolate ate is twice as potent as atropine. atropine. The dose is the same same for both drugs, drugs, regardle regardless ss of the route of administ administration. ration. Ketamine can also be administered orally.81 Bioavailability is approximately  17% following oral administration compared with 93% after intramuscular

0.4 mg/kg.88 The reported dosing regimens have varied from ketamine 4 to 10 mg/kg with midazolam 0.25 to 0.5 mg/kg. Situations may occur in the managementt of a mental men mentally ly impai impaire red, d, aut autist istic ic,, or older child in whom an intravenous line or an intramuscular injection cannot be administered without harm to the patient or the healthcare healthcare provider, provider, and who will not accept accept a face face mask. mask. Oral ketami ketamine ne alone or combined with oral midazolam can be used to establish a cataleptic state, facilitating facili tating treatm treatment ent of of the combati combative ve

lam was popular popular in the past. It was once once the most common intranasally administered ter ed medicat medication. ion. How However ever,, becau because se of an acidic acid ic pH, it produces produces irritatio irritation n to the nasall mucosa. nasa mucosa. The medicatio medication n if admin adminisistered slowly is discomforting and if  administered rapidly passes through the nose into the nasal pharynx and is swallowed. In a study study that compared compared oral oral to intranasal intra nasal administra administration tion of mida midazola zolam, m, children were found to be less tolerant of  the intranasal administration.92 Oral midazolam is probably the most

administration. 82,83 On Onse sett of se seda dati tion on occurs in approximately 20 minutes. Although doses reported have ranged from

patient.89,90 It may be helpful to solicit assistance from the patient’s caregiver or parent, as these individuals individuals may be aware aware

widely used premedicant premedicant in children. The recommended recomme nded dose of midazolam is 0.5 to 1.0 mg/kg mg/kg to a maxim maximum um of 20 mg. Mida Mida--

 

Pediatric Sedation

zolam 0.5 mg/kg achieves anxiolysis in 70 to 80% 80% of of patie patients. nts. The anes anesthet thetic ic depth depth may be potentiated by the administration of nitr nitrous ous oxide. oxide. The combin combined ed adminisadministration of 40% nitrous oxide oxide with midazolam 0.5 mg/kg has produced deep sedation in 12% of of patie patients. nts.93

Induction Agents Methohexital and propofol are rapid-onset short-acting agents that are effective for induction and maintena main tenance nce of of anes anesthes thesia. ia. Thes Thesee are the primary anesthetic agents for general anesthesia in oral and maxillofacial surgery performed in an office. office. The phar-

Clinical trials and case series have demonstrated propofol’s efficacy in pediatric patients.101–107 The proprietary formulation of propofol (Diprivan) (Diprivan) is licensed licensed by  the US Food and Drug Administration (FDA) for for use in children children > 3 years of age in the surgical setting.

Unlik Un likee ketamine, ketamine, midaz midazolam olam causes causes loss of of airwa airwayy muscle muscle tone. tone. Alth Although ough airairway obstruction is not common with dosess of 0.5 to 1.0 dose 1.0 mg/kg, mg/kg, airwa airwayy obstrucobstruction has been reported after 0.5 mg/kg oral midazolam.94 Th Thee incide incidenc ncee of air airwa way  y  obstruction may increase with the administration of nitrous oxide. In one one study the combined administration of 50% nitrous nitrous oxide and 0.5 mg/kg oral midazolam resulted in in a 56% incidence incidence of of upper airway obstruction in children with enlarged tonsils.95 Wit With h maint maintenan enance ce of airwa airway  y 

macology of these agents is is discussed discussed in Chapter Chap ter 5, “Ph “Pharmac armacology ology of Outpa Outpatien tientt Anesthesia Medications.” There are some important points to make relative to their use in the pediatric patient. Methohexital is an ultrashort-acting oxybarbiturate. oxyba rbiturate. It can be administered rectally,, IM, and IV. tally IV. The advantage advantage to to the recrectal administration administration of methohe methohexital xital is that the drug is administered in the presence of  the pare parents, nts, and, thu thus, s, the chi child ld is is aslee asleep p prior to parental separation. separation. Rectal adminadministrat ist ratio ion, n, ho howe weve verr, ca can n be distr distres essin sing, g, as

Transient pain at the site of injection is reported in approximately 10 to 20% of  patients given propofol. In the the pediatric patient this discomfort may result in gradations datio ns of mov movemen ement, t, whic which h may require require restraint of of the patient patient until induction is fully achieved. achieved. Propofo Propofoll may may also cause hypotens hypo tension ion and bradycardi bradycardia. a. The incidence is reported to be higher in the pediatric patient (17%) compared with that in the adult patient patient (3–10%). This usually is is not detected in the adult oral and maxillofacial surgery patient when a relativel relativelyy low 

patency, however patency, however,, oral midazolam doses doses of  0.5 to 0.75 mg/kg generally do not result in a change in oxygen saturation, saturation, heart rate, or blood pressure.96 The onset onset of of effe effect ct of oral midaz midazolam olam is within 20 minutes, minutes, and the duration duration of  sedation is 20 to 40 minutes. minutes. Patien Patients ts can generally be discharged within 60 to 90 minutes from the time at which the medication is administere administered. d. Midazolam is metabolized by the cytochrome cytoch rome oxidase oxidase system. system. Oral midazolam is subject to hepatic first-pass

discussed above. above. Metho Methohexital hexital can also be administered intramuscularly. Administration is quite painful, and there is no advantage to its use in office-based anesthesia compared with other available intramuscular agents. agents. Neith Neither er rectal nor intramusintramuscular administration is generally employed in ambulatory oral and maxillofacial surgery offices. Most frequently methohexital is administ administered ered IV. IV. Int Interes erestingl tinglyy, despite years years of safe administration administration in this this environment, enviro nment, the manufacturer’ manufacturer’ss package insert states that that the use of methohe methohexital xital in

initial dose (< 1 mg/kg) is typically used to achieve deep sedation or general anesthesia. Pediatric patients frequently need to be more more profoundl profoundlyy anestheti anesthetized. zed. This requires requ ires the admini administrati stration on of a greater greater dose of prop propofol ofol,, whic which h may may result result in a higher occu occurrenc rrencee of of hypot hypotensio ension n or or bradycardia in pediatric oral and maxillofacial surgery patients. Propof Propofol ol may also cause excitatory movement or myoclonus, the inciden incidence ce of whic which h is greater greater in the pediatric patient (17% vs 3–10%). The greatest potential concern with

metabolis metabo lism. m. Eryt Erythr hrom omyc ycin, in, cla clarit rithr hroomycin, myci n, protea protease se inhibitors, inhibitors, azole antifunantifungal medicatio medications, ns, fluvo fluvoxamin xaminee maleate, maleate, and grapefruit juice alter this cytochrome oxidase system and result in a higher and a more sustained midazolam plasma level.97,98 Higher doses of oral midazolam midazolam (0.75 to 1.0 mg/ mg/kg) kg) are associated associated with a greater incide inc idence nce of side effe effects cts.. The These se incl include ude loss lo ss of hea head d con contro trol, l, blu blurre rred d visi vision, on, and/or dysphoria dysphoria.. A paradoxic paradoxic reaction reaction may also occur in which the patient

the pediatric patient is not adequately  studied and thus not recommended. Propofol Propof ol is an alkylphenol. Its characteristics include rapid onset and short durat du ratio ion n of cl clin inic ical al effe effect ct,, si simi mila larr to methohexital. methohexita l. Its high clearance rate and minimal tendency for drug accumulation make it a more ideal anesthetic agent for ambulatory surgery in both adult and pediatric patients. In one study comparing comparing propofol to methohexital for anesthesia in pediatric patients undergoing procedures in a dental chair, chair, propofol was was associated

the use use of pro propofo pofoll in the the pediatric pediatric patient is that cases of fatal metabolic aciacidosis and cardiac failure, failure, termed propofolinfusion infu sion syndr syndrome ome,, have been reported in over a dozen children.108–112 These incidents have all been associated with prolonged intubation and propofol infusions. A review by the FDA concluded that propofol had not been shown to have a direct link to any pediatric deaths.113 Although the causal relationship between propofol and metabolic acidosis remains unproven, unpro ven, clini clinicians cians should should be aware of 

becomes more excited as opposed to sedated.. This is more sedated more common common in chilchil99 dren and adolescents.

with a 9% 9% incide incidenc ncee of ven ventric tricula ularr arrhythmias compared with a 32% incidence associated with methohexital. 100

the risk for this reaction in children and limit the dose dose and duration duration of propo propofol fol therapy accordingly accordingly..

113

 

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Inhalational Agents The orig origin in of of ane anessthesia is rooted rooted within dentistry. dentistry. The first anesthetic was nitrous oxide. Nitrous oxide oxide hass anxi ha anxiol olyti ytic, c, an anal alge gesi sic, c, am amne nest stic ic,, an and d 114,115 sedative effects. Although not a potent anesthetic anesthetic agent, nitrous oxide oxide possesses a wide margin margin of safety and has has few 

ing, lary laryngo ngospas spasm), m), whe wherea reass desf desflura lurane ne and isoflurane tend to irritate the airway if  used for mask induction.119–121 The blood blood and tissue tissue solubility solubility of an inhalationall agent is also important. These inhalationa properties influence the speed of of induction and emergence from anesthesia.

chospastic disease. All potent inhalational chospastic inhalational agents have myocardial depressant effects. The cardiovascular depressant effects are greatest with halothan halothanee use, use, which can result in hypotension and bradycardia. However How ever,, of greater significanc significancee is the ability of haloth halothane ane to sensitize sensitize the heart heart to

(if an any) y) resi residua duall side side effe effects cts.. An Anot other her advantage advanta ge of nitrou nitrouss oxide is its low low solubility. An anesthetic agent that has low solubility has rapid equilibration between the alveoli alveo li and the blood, blood, and the blood blood and the brain. This results results in both rapid onset and ane anesthe sthetic tic eme emergen rgence. ce. Als Also, o, nitr nitrous ous oxide may be combined with other anesthetic agents. agents. A deep sedative sedative or general general anesthetic state may be established with the coadministration coadmin istration of nitrous oxide oxide and an oral or parenteral parenteral agent. This may result in respiratory respirat ory impairment. Although nitrous nitrous

Agents that have a low solubility in blood have a more rapid induction and shorter emergence time. The blood blood gas solubility  solubility  coeffic coe fficient ientss of desfl desfluran urane, e, nitr nitrous ous oxi oxide, de, sevoflura sevo flurane, ne, isof isofluran lurane, e, and halothane halothane are 0.42 0. 42,, 0. 0.47 47,, 0. 0.6, 6, 1. 1.4, 4, an and d 2. 2.3, 3, re resp spec ecti tive vely ly.. These figures imply a more rapid onset and emergenc emergencee for desfluran desflurane, e, sevo sevofluflurane, and nitrous nitrous oxide. oxide. Since all anesthetic agents affect the pulmonary and and cardiovascular cardiovascular systems, systems, it is important to understand these effects. All potent inhalational agents depress

catecholamines with resultant dysrhythmias.. One study mias study report reported ed that that 48% of  pediatric patients anesthetized with halothane had arrhythmias compared with 16% of those induced induced with 8% sevofl sevofluurane. Patie Patients nts who who had had an increme incremental ntal induction inducti on of sevoflu sevoflurane rane had had even fewer arrhythm arrh ythmias. ias. Furt Furtherm hermore ore,, of the arrhytharrhythmias associated associated with halothane, halothane, 40% were ventricular ventric ular arrhythmias (consisting (consisting of ventricular tric ular tac tachy hycar cardia, dia, bige bigemin minyy, and coucouplets); with sevoflurane, sevoflurane, only 1% were were ventricular arrhythm arrhythmias ias (consistin (consistingg of single

oxide may potentiat potentiatee the effect of anothe anotherr agent age nt,, the disc discon onti tinu nuan ance ce of it can, can, li like ke-wise, revers reversee the anesthetic depth and promote a more rapid emergence.116–118 Although nitrous oxide lacks sufficient potency to solely induce general anesthesia, hal halotha othane, ne, sev sevoflu oflurane rane,, desf desflura lurane, ne, and isoflurane have sufficient potency to induce and maintain general anesthesia (Table 6-2). The prim primary ary bene benefit fit of an inhalational agent is for mask induction, and of the potent potent inhalatio inhalational nal agents, agents, only  halothane and sevoflurane are nonpun-

minute ventilation in a dose-dependent manner,, with a resulting increase in partial manner pressure pres sure of of carbo carbon n dioxide dioxide in arteri arterial al blood (PaCO2). Clinic Clinically ally the practitio practitioner ner will observe a decrease in tidal volume and a slight increase in respiratory rate. Although acceptable respiratory parameters can be maintained during spontaneous ventil ventilations, ations, of the two agents used for mask mask induction, induction, haloth halothane ane produces produces less respiratory depression than does sevoflurane.122 Not all respiratory effects are detrimental. detrimental. All inhalational inhalational agents are

ventricular ectopic beats).123 The occurrencee of these arrhythmi renc arrhythmias as may also be associated associa ted with the administration administration of local anesthetics containing epinephrine. Halothane is the only inhalational agent that is associated with arrhythmias with clinic cli nical al doses doses of of epin epinephr ephrine ine.. A limit limit of  of  1 µg/kg of epinephri epinephrine ne in patients patients receivreceiving halothane is recommended.124–126 Use of inhala inhalational tional agents agents is advantaadvantageous in the oral and maxillofacial surgeon’s office because they provide a general anesthetic state without intravenous

gent. These agents agents can be administered administered to an awake patient with minimal respiratory  complications compli cations (eg, coughin coughing, g, breath hold-

beneficial in that they produce bronchial dilatation and are advantageous in the manageme mana gement nt of the patien patientt with bronbron-

access. The access. Theref refore ore,, onl onlyy agent agentss that that are pleasant and nonirritating to the airway  can be used. used. Haloth Halothane ane has traditiona traditionally  lly  been the agent used by both anesthesiologists in the operating room and oral and maxillofacial surgeons in their offices. Sevoflurane appears to have the characteristics that most approximate the ideal inhalational inhala tional agent, agent, in that it is of sufficie sufficient nt potenc pot encyy, is nonpung nonpungent ent,, has a low blood blood and tissue solubility solubility,, and has limited limited cardiorespira dior espiratory tory effects effects.. Sevo Sevoflura flurane ne has replaced halothane in the operating rooms.

Table 6-2 6-2 Inh Inhalati alationa onall Anesthe Anesthetic tic Agent Agentss

 Agent

Nitrous oxide Halothane Sevoflurane Desflurane Isoflurane

Blood  Gas Solubility

0.47 2.40 0.69 0.42 1.40

 Maximum Acceptable Concentration (%) 1–12 yr

— 0.87 2.5 7.98–8.72 1.60

Adult 

105.00 0.76 1.70 7.30 1.20

Adapted from Cauld Adapted Cauldwell well CB. Induct Induction,maintenanc ion,maintenancee and emerge emergence. nce. In: Greg Gregory ory GA, edito editor.Pediatri r.Pediatricc anesthesia. anesthesia. 2nd ed. New York: Churchill Livingston; 1989.

There are several variations in maskinduction inductio n tech techniqu niques. es. Firs First, t, the inh inhalaalational agent may be administered with a

 

Pediatric Sedation

combination of nitrous oxide combination oxide and oxygen or 100% 100% oxygen oxygen.. The combin combination ation of  nitrous oxide with the potent vapor agent decreases decrea ses the percen percentage tage of vapor agent agent required to achieve an anesthetic depth. The decrease in minimum alveolar concentration (MAC) for halothane is signif-

dental extractions lasting between 4 and 6 minutes have not demonstrated a more rapid recovery with sevoflurane.133 In one study, in which children were subject to a 4-minute anesthesia, anesthesia, time to eye opening was 102 seconds with halothane and 167 seconds with sevoflurane.134

is that it is a gastric irritant and is associated with nausea and vomiting. Antihistamines Antihistamin es are commonly used in medicine and dentistry for their antipruritic and antiemetic effects. effects. When used for these conditions, conditions, sedation is frequently  frequently  an unw unwant anted ed side side eff effect ect.. Ho Howev wever er,, the

icantly clinically greater for halothane than for sevoflura sevoflurane. ne. This most likely likely is related to the difference in solubility of  the two potent inhalational agents. Another variation in mask induction pertains to the concentration concentration of inhalat inhalational ional agent administered. administered. The practitioner may  administer an incrementally increasing concentration conc entration of an agent agent (eg, (eg, incre increasing asing an agent by 0.5–1% after a few breaths) or a high initial initial concentrat concentration ion of an agent (eg, (e g, se sevo vofl flur uran anee 8%). 8%). Al Alth thou ough gh one one would expect that sevoflurane would

The last factor that needs to be considered both in comparing sevoflurane and halothane and in selecting an anesthetic agent for the office is the the toxicity toxicity of each drug. Halothane is metabolized metabolized in the liver liver to a trifluoro trifluoroacety acetylate lated d product, product, which binds liver proteins promoting an immunologic response that can result in hepatic injury. 135,136 The incidence incidence,, which may be as high high as 1 in 6,000 cases of anesthesia in adults, is significantly lower lower in the pedi pe diatr atric ic popul po pulat atio ion. n. Sevo Se vofl flura urane ne,, although not associated with liver toxicity,

sedative effects can be used to advantage, and antihistamines such as promethazine and hydroxyzine are frequently combined with other drugs such as chloral hydrate and meperidine to potentiate the sedative effect of the primary anesthetic anesthetic agent agent and to provide antiemetic antiemetic effects. effects. The sedative effects of antihistamine antihistaminess may last last between 3 and 6 hours, and when used alone do not provide anxiolysis. The oral transmucosal administration of a sedative sedative medication is appealing. appealing. Fentanyl citrate is available as a lozenge on a

have a more rapid speed of inductio induction, n, the differences between sevoflurane and halothane have not been consistently  demonstrated.121,127 The difference in speed of inductio induction n appears to be less less distinguishable when a high concentration of halotha halothane ne is used. Simila Sim ilarr to speed speed of of ind induct uction ion,, ane anessthetic emergence is dependent on several variables. variabl es. Agen Agents ts that have have a low blood blood solubility coefficient should have a shorter emergence emergence time. time. Seve Several ral studies have have shown that desflurane, which has the low-

has been associated with the potential for renal toxicity.137,138 The drug undergoes hepatic metabolism, which produces produces inorganicc fluoride. gani fluoride. How However ever,, the rapid rapid elimielimination of sevoflurane minimizes minimizes the renal renal fluo fl uorid ridee exposur exposure, e, wh whic ich h proba probabl bly  y  accounts accoun ts for the lack of clinical renal renal dysfunction func tion,, despi despite te some repo reports rts of serum fluoride levels > 50 µmol. µmol. Renal injury has also been associated with the formation of  compoun com pound d A, A, whic which h is a product product of the reaction between sevoflurane and CO2 abso ab sorb rben ents ts.. Mos ostt of th thee data data,, ho howe weve verr,

stick. The recommended recommended dose dose is between between 10 and 20 µg/kg. Bioavailabil Bioavailability ity is between 33% in children and 50% in adults.139 The difference in bioavailability  results resu lts from from the amount amount of drug that that is swallowed and and the amount amount of drug that is absorbed absorb ed through through the oral mucos mucosa. a. The drug provides both analgesia and sedation. Onset of of analgesia precedes the onset onset of  sedation. Analgesia also lasts lasts for for 2 to 3 hours, hours, provid providing ing some some postope postoperative rative pain control. control. Adver Adverse se side effects associated with the fentany fentanyll lozenge include a high

est blood solubility solubility coefficient, has a very  very  rapid anesthetic emergence (5–7 min), and haloth halothane, ane, whic which h has the the highest highest blood solubility solubility coeffic coefficient, ient, has a more prolonged recovery (10–21 min). 128–132 Sevoflurane has been shown, although not consistently,, to have consistently have a more more rapid anesthetic emergence for intermediate- and long-duration anesthetics compared with halothane . However, t ypi ypiccal ly ly t he he required state of anesthesia for a pediatric dental procedure in the office is brief, lasting < 10 minutes. minutes. Recovery from from anesthe-

suggest that compound A does not induce renal toxicity in humans.

incidenc incide ncee of nau nausea sea and vo vomit miting ing,, and pruritus. The major adverse effect effect associated with with the use of of fenta fentanyl nyl citrate citrate is is a higher incidence incidence of respir respiratory atory depression depression than that seen with other sedative medications. The respiratory depression associated associated with the fentanyl lozenge may last beyond the sedative effect.140

sia is also dependent on the duration of  the anesthesia. Clinical studies comparing sevoflurane and halothane for pediatric

favorable a work environment as the anxiolytic iolyt ic effe effect ct of a benz benzodiaz odiazepin epine. e.50 Another Anoth er disadvantage disadvantage of chloral hydrate hydrate

Other Medications Chloral hydrate is an alcohol-based alcohol-based sedative. sedative. It produces produces a sleep from which which one is easily roused, roused, in which the cardiorespiratory effects are consistent with those that occur with natural sleep. sleep. The onset onset of chloral hydra hydrate te is slow (30–60 min), min), its duration is variable (2–5 h), and it lacks the anxiolytic anxiolytic effects effects of benzodi benzodiazepine azepines. s. The sedative sedative effect of  chloral hydrate does not produce as

Perioperativee Complicatio Perioperativ Complications ns  Laryngospasm Intraoral surgery in the anesthetized nonintubated patient renders the patient susceptible to airway obstruction and airway  irritation. Such irritation can can result result in a

115

 

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laryngospasm, which is is the apposition of  the supraglottic folds, the false vocal cords, cords, and the the true voca vocall cords. cords. The larynlaryngospasm may be sustained and may  become progressively worse as the supraglottic tissues fold over the vocal cords during force forceful ful inspirato inspiratory ry efforts. efforts. The

itive airway pressure cannot “break” laryngospasm laryngospas m in the presenc presencee of of complete airway obstruction obstruction and may, may, in fact, worsen laryngospasm by forcing supraglottic tissues downward to occlude the glottic opening. For the laryngospasm that is refracto-

whereas end-tidal CO2 is the most sensitive sign of maligna malignant nt hyperthermia. hyperthermia.142,143 Another potential life-threatening complication complicat ion following the administration of succiny succinylcholine lcholine is hyperkalemic hyperkalemic cardiac arrest. Hyperkalemic cardiac cardiac arrest follows the administration of succiny succinylcholine lcholine in

incidence of laryngo incidence laryngospasm spasm is 8.7 8.7 per per 1,000 patients in the total population and 17.4 per 1,000 in patients patients < 9 years years of age.39 Thee trea Th treatme tment nt of of la laryn ryngo gosp spas asm m depends on whether the airway obstruction is complete complete or incomplete. The single diagnostic feature that distinguishes complete from incomplete airway obstruction is simply the absence absence or presence of sound. If ther theree are are inspirato inspiratory ry or expirat expiratory  ory  squeak squ eaks, s, sou sounds nds,, grun grunts, ts, or whi whistl stles, es, the then n chances are the child has incomplete airway obstructi obstruction. on. Airwa Airwayy obstruction obstruction of 

ry to continuous positive airway pressure, a neuromuscular blocking agent should be administered. The ideal agent should should have rapid onset. For the nonintubated nonintubated patient, rapid recovery recovery is also desirable. Succin Succinylylcholine is the only neuromuscular blocking agent that provides these effects.

patients with undiagnosed myopathies; succinylcholine induces rhabdomyolysis, which causes hyperkalemia leading to bradycardia/asystolic bradycardia /asystolic rhythm. rhythm. Several case reports have appeared in the literature emphasizing this potential risk in the pediatric patient, which exists because Duchenne’s and Becker’s muscular dystrophies may go undiagnosed until the ages of 6 and 12 years, resp respecti ectively vely..144,145 Alternative neuromuscular agents have been developed that can provide rapid onset and should be used for elective

either type requires initial treatment with a patency-preserving maneuver such as the jaw-thrust/chin-lift maneuver. Because incomplete airway obstruction may rapidly become become complete, complete, signs and an d sympto symptoms ms of obs obstru truct ction ion (eg, (eg, tra tra-cheal tug, paradoxi paradoxicc respiration) respiration) should should be treated aggressively aggressively.. The first maneuver is to apply gentle continuous positive airway pressure with 100% O 2 by face mask. An effective effective techniqu techniquee to deliver deliver gentle positive pressure is to “flutter the bag.” In this technique the reservoir bag is

tration of the succinylcho succinylcholine line to prevent a bradycardia secondary to the muscarinic effec eff ectt of suc succi ciny nylc lcho holi line ne.. If in intra trave veno nous us access is not not available, available, succin succinylchol ylcholine ine may be administered intralingually or IM (succinylcholine 4 mg/kg).141 There are several potential complications associat associated ed with the use of succi succinylnylcholine. choli ne. These include include myalgias, myalgias, malign malignant ant hyperthermia hypert hermia,, masset masseter er muscle muscle rigidity, rigidity, and hyperkalemic cardiac arrest in patients with undiagno undiagnosed sed myopat myopathies hies.. In some children child ren the the administratio administration n of succi succinyl nyl--

very rapidly squeezed and released in a staccato stacc ato rhythm, rhythm, simila similarr to what what one would see with an atrial atrial flutter flutter of of the heart. In essence, essence, one performs performs a manual high-frequency oscillatory ventilation with wi th th this is te tech chni niqu que. e. If th thee pa pati tien entt improves, improv es, anesthe anesthesia sia and normal ventilation ti on may may be res resume umed. d. Ov Overu eruse se of of th thee high-pressure flush valve to fill the breathing circuit and anesthetic bag may  dilute potent anesthe anesthetic tic gases gases (if being used) and lead lead to a lighter lighter plane of anesthesia in in the child. child. In addition, addition, high prespres-

choline can result in masseter muscle Three approaches to emergency surgical spasm. Masse Masseter ter muscle muscle spasm may indiindi- openi opening ng of the airway airway are mentione mentioned d in cate a susceptibility to malignant hyper- the literature: emergency tracheot tracheotomy omy,, thermia, but it can also be isolated and not emerge emergency ncy cricothy cricothyroto rotomy my,, and emerprogress progr ess to malignant malignant hyperthermia hyperthermia.. The gency transtracheal ventilation.146 In the anesthetic team needs to differentiate experi experience ence of most, emerge emergency ncy tracheototracheotobetween an isolated spasm and a prodromal my cannot be performed rapidly enough sign of an impending emergency to make a in dire dire situatio situations. ns. Like Likewise, wise, transtra transtrachea cheall decision regarding regarding the continuation of the  jet ventilation is extremely hazardous in anesthetic and surgical course. In a tertiary  children because barotrauma may occur environment with appropriate monitoring, owing to the restricted egress of ventilatothe anesthesia may be continued with ry ga gas. s. Th Ther eref efor ore, e, wh when en endo endotra trach chea eall observation observat ion for the develop development ment of other intuba intubation tion cannot cannot be accomplishe accomplished, d, the

sure applied to the airway may force gas down the esophagus and into the stomach, reducin reducingg ventilation ventilation even more. more. Pos Pos--

systemic signs reflective systemic reflective of the hypermetahypermetabolic state of malignan malignantt hyperthermi hyperthermia. a. Tachycardia is usually the earliest sign,

Succinylcholine  If int intra rave veno nous us acce access ss is availa available ble,, suc suc-cinylcholine 0.5 to 1.0 mg/kg is administered. ter ed. If the child child is is hypoxe hypoxemic, mic, atr atropin opinee 0.02 mg/kg should preceed the adminis-

situations. Rocuron Rocuronium ium may be used when succinyl succ inylchol choline ine is contrai contraindica ndicated. ted. Its onsett is rapid, onse rapid, how however ever,, with a consi considerderably longer longer duration. duration. The administration administration of lidocaine topically to the vocal cords may also also be effective. effective. Succ Succinyl inylchol choline ine remains the most ideal drug for the management agem ent of laryn laryngospa gospasm sm and emergent emergent tracheal intubation and is the essential drug for managing laryngospasm in the oral and maxillofacial surgery office.

Cricothyrotomy 

most rapid method for oxygenating the patient in an emergency situation is cricothyrotomy.147

 

Pediatric Sedation

 Nausea and Vomiting  Vomiting  Postoperative nausea and vomiting (PONV) is a cause cause of morbidity in pediatric patients. patie nts. Eve Even n mild PONV is associa associated ted with delayed delayed discharge, discharge, decreased parental satisfaction,, and increased use of resourc satisfaction resources. es. More severe complications associated with PONV include dehydration and electrolyte disturbances, or hypox hypoxemia emia secondary to airwayy obstruction airwa obstruction or aspiratio aspiration. n. PON PONV V occurs in 6 to 42% of all pediatric surgical surgical patients. The incidence incidence is variable variable dependingg on age in age of of th thee pati patien ent, t, th thee sex sex of th thee patient (there is a greater incidence in females > 13 yr), the anesthetic agents agents used, and the surgical surgical procedure. procedure. Fortun Fortunately ately,, severe or intractable PONV is less common, occurring in 1 to 3% of of pediatric patients.148 Anesthetic drug selection can have an

brainstem centers, centers, and solitary tract nucleus. These structures structures are rich rich in dopamindopaminergic er gic,, mu musc scari arini nic, c, se sero roto toni nine nergi rgic, c, hi hista sta-minic, mini c, and opioid opioid rece receptor ptors. s. Bloc Blockade kade of  of  thesee receptor thes receptorss is the mechanism mechanism of the antiemet anti emetic ic action action of drugs. At the presen presentt time there are no drugs known that act

pramide are are well tolerated tolerated by by adults, but children are prone to dystonic reactions. For this reason, reason, metoclo metoclopramide pramide is comcombined frequently with diphenhydramine to decrease this incidence. Although metoclopramide has been used successfully to reduce the incidence incidence of PONV in high-risk  high-risk 

directly on the emetic center. Routine administration of antiemetic agents to all children undergoing surgery  is not justifiable as the majority do not experience PONV or or have, have, at most, one or two episodes. The agents used are the same as those used to manage PONV in the adult. The following following discussion identifies points significant to the management of  PONV in the pediatric patient.

children, it is not as effective as droperidol children, droperidol or the newer serotonin antagonists.151,152

Phenothiazines The phenothiazines are believed to exert their antiemetic effects

Histamine Antagonists The histamine receptor antagonists are weakly antiemetic drugs with profound sedative effects, which make them less suitable for use in postoperativee patients. They are frequentpostoperativ frequently combined with other anesthetic agents in an oral cocktail for their sedative and antiemetic antie metic effec effects. ts. Thes Thesee drugs may be useful for controlling emesis resulting from vestibular vestibular stimulation, stimulation, as occurs occurs in

eff effect ect on on midazolam the inc inciden idence ce of o f PON PONV V. Pre Pre-operative has been associated with reduced PONV in children. 149 Subsedativee doses of propofo sedativ propofoll also provide antiemeti anti emeticc effects. effects. This contras contrasts ts with methohexital, methoh exital, which is associate associated d with a higher incidence incidence of PONV than is propopropofol in adults. Studies are lacking lacking comparcomparing the the incide incidence nce of of PON PONV V of the these se two two agents agen ts in a pediatric pediatric populati population. on. Pre Pre-medication with opioid analgesics increa inc reases ses the the risk of PON PONV V. Oral trans trans-mucosal mucos al fentanyl fentanyl citrate in in doses of 5 to

primarilyy by ant primaril antago agonis nism m of cen central tral dopaminergic receptors in the chemoreceptor cept or trigger trigger zon zone. e. Low dose dosess of chlo chlorrprom pr omaz azin ine, e, pr prom omet etha hazi zine ne,, an and d pe perrphenazine are effective in preventing and controlling control ling PONV PONV. These drugs are frefrequently combined with opioids (when administered orally by pediatric dentists) to decrease decrease the emetic effect effect of the opioid. All phenothiazines phenothiazines are capable capable of producing extrapyramidal symptoms and sedation, which may complicate complicate postoperative postoperative care ca re.. Th Thee degr degree ee of of se seda dati tion on var varie iess

patients with motion sickness or after middle ear surgery. surgery. They also counterac counteractt the extrapyramidal effects effects of the more efficacious dopamine recepto receptorr antagonists.

20 µg/kg is associated with PONV in almost all patients.140 As discussed above, ketamine is an excellent agent for pediatric sedation sedation.. An unfortuna unfortunate te adverse adverse effect associated with ketamine is a reported reporte d incidence incidence of PONV that is as high as 50%. Nitrous oxide also has emetic effects. How However ever,, conc concentratio entrations ns < 40% are less likely to cause PONV. Vomiting is a complicated response mediated by the emetic center located in the latera laterall reticula reticularr formation formation of the medulla. This center center receives receives input input from

between phenothiazin phenothiazines, es, with little sedation produced by perphenazine compared with the other phenothiazines.150

adults the adults the use of of gly glyco copyrr pyrrola olate, te, a drug that does not cross the blood-brain barrier,, has been associate er associated d with three times times the need for rescue antiemetic therapy  compared with atropine.153 Transdermal scopolamine has been used successfully to reduce PONV in children receiving morphine but is associated with a significant increase in sedation and dry mouth. 154 Other potential side effects include dysphoria,, con phoria confusion fusion,, disorie disorientati ntation, on, halluc halluciinations, natio ns, and visual disturbances. disturbances.

several areas within the CNS,including CNS, including the chemore che morecept ceptor or trigger zone, zone, vesti vestibular bular apparatus, cerebellum, higher cortical and

ergic and cholinergic actions and increases motility from the distal esophagus to the ileoc ile ocec ecal al valve valve.. Hi High gh doses doses of met metoc oclo lo--

Benzamides The benzamide derivative metoclopramide has antiemetic and prokinetic effects and is the most effective antie an tieme metic tic of of th this is class. class. It Itss antieme antiemeti ticc effects are mediated mediated by antagonism antagonism of central dopaminergic dopaminergic recepto receptors, rs, and at high high doses it also antagonizes serotonin-3 recepto rec eptors. rs. In the gastroint gastrointestin estinal al tract metoclopramide has significant dopamin-

Muscarinic Receptor Antagonists The vestibular apparatus and the nucleus of  the tractus solitarius are rich in muscarinicc and histamin carini histaminic ic receptor receptors. s. Muscarinic receptor antagonism is effective in preventing emesis related to vestibular stimulation stimul ation,, which may may be the the mechamechanism nis m of mor morphi phinene-ind induc uced ed PO PONV NV.. In

Serotonin Receptor Antagonists Serotonin antagonists were discovered serendipitously when compounds struc-

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turally related to metoclopramide were found to have significant antiemetic effects but lacked dopamine receptor affinity. These drugs produce pure antagonism of  the serotonin-3 receptor receptor.. Ondansetron was the first drug of of this class to become available for clinical use in 1991. Since that time

patient anat patient anatomic omically ally,, phy physiolo siological gically ly,, and behaviorally.. Beyond these differences behaviorally differences the pediatric population is a diverse group within itself. itself. Oral and and maxillofacial maxillofacial surgeons are involved with the management of patients with craniofacial syndromes as as well as other physical or mental impair-

phenidate, dextr phenidate, dextroamphe oamphetamin tamine, e, or pemoline. Meth Methylphe ylphenidate nidate is the most most commonly mon ly prescrib prescribed ed drug for ADHD ADHD.. In addition to its use in the management of  ADHD ADH D, 1 to 2% 2% of the US US high-s high-scho chool ol population without a diagnosed medical condition is reported to abuse this

granisetron, and dolasetr granisetron, dolasetron on have been introduced intro duced.. This class class of of pure serot serotonin onin-3 -3 receptor antagonists is not associated with the side side effects effects of dopami dopamine, ne, muscar muscarinic, inic, or histamine histam ine receptor receptor antagonists. antagonists. The most serious side effects effects of ondansetron are are rare hypersensitivity reactions.155 Gastric emptying and small bowel transit time were not affected affe cted by ondansetron ondansetron.. Asym Asymptom ptomatic atic brief prolo prolongatio ngation n of the P–R P–R interval interval and and the QRS complex of the electrocardiogram electrocardiogram have been reporte reported d in adults, adults, but rapid intravenous intrave nous infusion of ondanse ondansetron tron in

ments. The craniofa ments. craniofacial cial syndrome syndromess may  result in anatomic and physiologic alterations as well as mental disabilities. Pot Potenential airway abnormalities include macroglossia glos sia,, mic microg rognat nathia hia,, cho choana anall atr atresi esia, a, limited mouth opening, kyphoscolio kyphoscoliosis, sis, or cervical spine abnormalities. abnormalities. These abnormalities may make the patient more susceptible to upper airway obstruction and compromise spontaneous ventilation, oxygena oxy genation tion,, mask ven ventilat tilation, ion, or laryngosco gos copy py and and intuba intubatio tion. n. Ma Many ny of of the these se patients may have significant cardiovascu-

drug.160 These drugs increase the bioavailability abi lity of neu neurot rotran ransmit smitter ters. s. The drug drugss tend to cause an increase in blood pressure and and heart rate. Adv Adverse erse effects effects are similarr to that of other sympathomi simila sympathomimetic metic agents. agent s. CNS effects effects include restlessn restlessness, ess, dizzin diz ziness ess,, tre tremor mor,, hyp hypera eracti ctive ve reflex reflexes, es, weak we akne ness ss,, in inso somn mnia ia,, de deli liriu rium, m, an and d psypsychosis. Cardiovascular effects may include head he adac ache hes, s, pa palp lpit itat atio ions ns,, ar arrh rhyt ythm hmia ias, s, hypertension followed by hypotension, and circulatory collapse.161 Perioperative Periope rative management management of a patient

children was not associated with changes in heart rate, arteria arteriall pressur pressure, e, or oxy oxyhemohemo156 globin saturation. Psychomotor and respiratory function were unaffected by  ondansetron. ondanse tron. Proph Prophylactic ylactic ondanse ondansetron tron 0.05 to 0.15 mg/kg IV or orally reduced the incidence of PONV in children children after a variety of surgica surgicall procedures. procedures.157 Glucocorticoids (dexamethasone, methylprednisolone) exert antiemetic properties by a mechanism as yet unknown.. These drugs known drugs have been been used successfully in the postoperative setting to pre-

lar disease associated with their syndrome. Mental impairment may also be associated with several congenital congenital syndromes. Alternatively,, physical disabilities are not always natively associated with mental mental impairments. impairments. The health care provider must avoid treating these patie patients nts as if they were were mental mentally  ly  impaired because of of their inability to to communi mu nica cate te no norma rmall llyy. La Last stly ly,, su subs bsta tanc ncee abuse among children and teens has reached epidemic proportions. This section reviews the clinical presentation and anesthetic management of 

on a psychostimulant (such as methylphenidate) includes recognizing signs and symptoms suggestive of inappropriat inappropriatee use. If there is a suggestion regarding regarding overdose of  the medication, medication, the surgery should be postpostponed. pone d. Ho Howeve wever, r, when the medic medicatio ation n is used appropriately, appropriately, it is generally well tolerated.. If ther ated theree are are no indic indicatio ations ns of adv adverse erse events, the medication should should be continued throughout the perioperative period. Chronic use of the medication may may decrease anesthetic requirements. The anesthet anesthetic ic managemen managementt of thes thesee

vent PONV. PONV. Dexamethasone in doses up to 1 mg/kg IV (maximum dose 25 mg) was effective in reducing postoperative vomiting in children after tonsillectomy. tonsillectomy.158 However, low-dose dexamethasone 0.15 mg/kg IV was not as effective as perphenazine 70 µg/kg IV in preventing emesis after tonsillectomy in children.159 This class of  drugs is better used in combination with another antiemetic than as the sole agent to prevent PONV.

some patients with special considerations. considerations.

patients is dependent on the level of cooperat ope ration ion of the pat patien ient. t. Pr Preop eopera erativ tivee sedatives may be used. Many of these indiindividualss allow the placemen vidual placementt of an intravenous catheter catheter.. Howeve However, r, for the patient in whom intravenous access cannot be establishe estab lished, d, ket ketamine amine (with or or without without midazolam) administered orally or IM is effective and not contraindicated owing to the chronic chronic use of a psychostimulant. psychostimulant.

 Attention Deficit Hyperactivity  Hyperactivity  Disorder

Special Considerations

Attention deficit hyperactivity disorder (ADHD) is defined as a persistent severe pattern patt ern of inat inattent tention ion or hyperacti hyperactivityvityimpulsivity symptoms compared with other children at a comparable developmental level. Three subtypes of ADHD are identified: a predominantly hyperactiv hyperactiveeimpulsive type, a predominantly predominantly inattentive type, and a combin combined ed type. It is estiesti-

Oral and maxillofacial surgeons treat a diverse dive rse grou group p of pati patients. ents. Simp Simplisti listicall callyy, the pediatric patient differs from the adult

mated to affect affect up to 5% of children. Medical therapy frequently includes psychostimulants such as methyl-

 Autism  Au tism Autism is a complex developmental disability that typically appears during the firstt 3 year firs yearss of life life.. The resu result lt of of a neuroneurologic disorder that affects the functioning

 

Pediatric Sedation

of the brain, autism is the third most comcommon developmental disability in the United States and occurs in approximately 2 to 4 per 10,000 live births. 162 Autism is four times more prevalent in boys than in girls and kno knows ws no no racia racial, l, eth ethnic nic,, or soci social al bounda bou ndarie ries. s. Fam Family ily in inco come, me, lif lifest estyle yle,, an and d

with a potent vapor agent or intramuscular ketamine ketami ne may be consider considered; ed; howev however, er, the individual may be too physically strong and combative combative for these these techniques. techniques. An alternative that should be considered (even in the noncombative individual) is oral administ admi nistrati ration on of a premedic premedicant ant of of ket ketaa-

that > 50% of patients with cerebral palsy  palsy  do not demonstrate mental impairment. Dysarthria or speech abnormalities secondary to a lack of coordin coordination ation in muscle movemen mov ementt of the mouth mouth can be seen seen in athetoid athet oid cere cerebral bral palsy palsy.. This muscle abnormality should not be confused with

educational levels do not affect the chance of autism’ autism’ss occurrence. occurrence. Autism impacts the normal developmentt of the brai men brain n in the the areas areas of soc social ial interaction and communication skills. Children and adults with autism typically  have difficulties in verbal and nonverbal communi com municati cation, on, soci social al inte interacti ractions, ons, and leisuree or play activiti leisur activities. es. The disorder disorder makes it difficult for them to communicate with others and relate to the outside world.163,164 In some cases aggressive and/or self-injurious behavior may be present.

mine or ketamine and midazolam.89 Alterations in management must be carried over into the postoperati postoperative ve period, period, in which many patients with behavioral or mental impairments are more agitated. Restraint may be necessary to prevent premature remova removall of the intravenou intravenouss line, wound disturbance, disturbance, or self-injury. self-injury.

Cerebral palsy Cerebral palsy is a group group of neur neurologi ologicc disorders that are characterized by  impaired impai red control control of mov movemen ement. t. The cliniclini-

mental impairment. Seizures are seen seen in up to 35% of patients with spastic spastic cerebral palsy pal sy.. The lack lack of of mus muscl clee coordi coordina natio tion n contributes to drooling and dysphagia. The inability to handle the secretions and the incompetent pharyngeal swallow  reflex increase the risk of of laryngospasm. Individuals with impaired neurologic function may also have an increased incidence of gastroesopha gastroesophageal geal reflux. reflux. Several factors must be taken into consideration sideratio n in treating treating these these patients. patients. The spasticity and lack of coordi coordination nation can

Persons with autism may exhibit repeated body moveme movements nts (hand (hand flapping, flapping, rock rock-ing), ing ), unu unusua suall resp respons onses es to peo people ple,, or attachments to objects and resistance to changes in routines. routines. Children with autistic disorders may may include a subgroup subgroup of individuals with associated psychiatric symptoms, to ms, inc includi luding ng aggre aggressi ssion, on, sel self-a f-abusi busive ve behavior,, and violent behavior violent tantrums, and oftenoftentimess necessita time necessitate te the use of of psyc psychiatr hiatric ic medications; antipsych antipsychotics otics are the the most prevalently prescribed medications in this group.165 The autistic patient may also be

cal manifestations are variable and are dependent on the site site and extent of injury. Theree are four Ther four classifica classifications tions:: spasti spastic, c, athet ath etoid oid,, ata ataxic xic,, and mixed. mixed. Spa Spasti sticc ce cere re-bral palsy is the most common form and affects affe cts up to 80% of of the patient patients. s. Pa Patien tients ts with spastic cerebral palsy present with musclee hypert muscl hypertonic onicity ity,, hyperr hyperreflex eflexia, ia, muscl musclee contractu con tractures, res, musc muscle le rigidity rigidity,, and muscle muscle weakness. weak ness. The pattern pattern of dysf dysfunct unction ion can be further classified into monoplegia (one limb),, diple limb) diplegia gia (both arms or both legs), legs), hemiplegia hemiple gia (unilat (unilateral), eral), triplegia (three

contribute to a hyperactive gag reflex. Anxiety can aggravate the involuntary movements. Nitr Nitrous ous oxide oxide sedation sedation may be effective in reducing these responses.167 Severe contractures may make positioning the patien patientt difficult difficult.. Co Contra ntractur ctures, es, whi which ch may result result in scolio scoliosis, sis, can result result in a restrictive lung disorder disorder.. The patient’ patient’ss hypotonia may necessitate stabilization of  the head (even for the nonsedated patient). If the patient patient is to be sedated, sedated,muscle muscle weakweakness may predispose the patient to impaired respiration respirations. s. This may may be comcom-

prescribed medications similar to those prescribed for ADHD. Management Manage ment of of these patients in the oral and maxillofacial surgery setting requires respect for the autistic child’s need for ritualistic behavior, which may result in tantrum-like rages with any disruptions of  routine rou tine.. Pr Providi oviding ng a calm environmen environmentt with minimal stimulation and consideration of all associated associated pharmacologic pharmacologic influences aids in the managemen managementt of these patients pati ents.. Pre Premedi medicati cation on with a benzodiazepine may be beneficial. beneficial. Howev However, er,

limbs), and quadri limbs), quadriplegi plegiaa (all (all limbs) limbs).. The severity of the contractures contractures may may result in spinal deformities such as scoliosis. Athetoid or dyskinetic cerebral palsy is characterized characterize d by chorei choreiform, form, tremor tremor,, dystoni to nia, a, and hypot hypoton onia. ia. The invo involun lunta tary  ry  movements seen with athetoid cerebral palsy often increase with emotional stress. Ataxic cerebral palsy is characterized by  poor coordination and jerky movements. Associated medical conditions include mental retardation, retardation, speech abnormalities, abnormalities, seizures, seizu res, droo drooling, ling, dysph dysphagia, agia, and gastr gastroo-

pounded by medications prescribed to control the spasticity or seizure disorder. Conscious sedation may be contraindicated because beca use of the inabil inability ity to handle handle oral oral secretions secreti ons and the risk of gastroe gastroesophagea sophageall reflux. It may be necessary necessary to protect protect the airway with the the placemen placementt of an endoendotracheal tube. tube. In the event that that the airway  requiress emergent require emergent intubation, intubation, the use of  of  168 succinylcholine is not contraindicated.

establishing an intravenous access still may  not be possible, possible, and an alternativ alternativee technique may be required. required. A mask induction induction

esophageal reflux.166 Mental impairment is most common in patients with spastic cerebral palsy. palsy. It is important to recognize recognize

mon chromosomal disorder occurring at a rate of 1.5 per 1,000 live births and and is usually characterized by mild to moderate

Cerebral Palsy 

Down Syndrome  Down syndro syndrome, me, or trisomy trisomy 21, is a com-

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mental retardation, retardation, cardiovasc cardiovascular ular abnormalities, mali ties, and craniofacia craniofaciall abno abnormali rmalities. ties. Craniofacial abnormalities that have an impact on the anesthetic management of  these patients include macroglossia, micrognat micr ognathia, hia, and a short short neck neck,, putti putting ng these patients at increased risk for airway 

gressive loss of skeletal muscle function. There are are nine types of muscular dystrodystrophies,, the most phies most common common and dramatic dramatic being Duchenne’s disease (pseudohypertrophic muscular dystroph dystrophy). y). Symptoms typically typica lly begin begin between between the ages ages of 2 to 5 years, often with the patient becoming

choline is contraindicated because it can cause rhabdomyolysis with a resultant hyperkalemia. hyperka lemia. Although all patients patients may  have a slight increase in extracellular potassium after the administrati administration on of succin succinylylcholine, cholin e, the increase increase in a patient with muscular dystrophy can cause hyperkalemic

obstruction during sedation. sedation. Enlargement of the lymphoi lymphoid d tissue tissue may also also place place these patients at risk for upper airway  obstruc obs tructio tion. n. In addi additio tion, n, the these se patie patients nts have generalized joint laxity that may be associat asso ciated ed with subluxati subluxation on of the temtemporomandibular joint during airway  manipulat mani pulation. ion. Intu Intubatio bation n is usual usually ly not difficult, diffi cult, but subglotti subglotticc stenosis, stenosis, whic which h is present in up to 25% of Down syndrome syndrome individuals,, may necess individuals necessitate itate a smallersmallerdiameter endotracheal tube. Atlantoaxial instability occurs in

wheelchair-bound by age 12 years. Death wheelchair-bound usually occurs between ages 15 and 25 years, usually secondary secondary to pneumonia or congestive congestive heart failure. Becker’ Becker’ss muscular dystrophy is the next most common form of musc muscular ular dystro dystrophy phy.. Its manifes manifes-tation tat ionss are simila similarr, alt althou hough gh milder milder,, to thosee of Duc thos Duchenn henne’ e’ss disease. disease. Its onse onsett is later, late r, and the progre progression ssion of the disease disease is slow sl ower er.. Ti Time me to to onse onsett of di dise seas ase, e, be bein ingg wheelcha whee lchairir-boun bound, d, and death death are 12, 30, and 42 years, respectiv respectively ely..169 The anesthet anesthetic ic managemen managementt of these

cardiac arrest. cardiac arrest. The avoid avoidance ance of succin succinylylcholine and volatile inhalational agents is also recommended recommended because because of the association of Duchen Duchenne’ ne’ss disease with increased increased malignantt hyperthe malignan hyperthermia. rmia. Non Nondepolariz depolarizing ing muscle relaxan relaxants ts may may be used; howev however, er, a prolonged recovery time is seen in patients with muscular dystrophy dystrophy.. The response to reversal revers al agents is also variable. Additio Additionalnally,, patie ly patients nts are are susceptibl susceptiblee to an unexplained late respiratory depression. Ambulatory surgery may be unadvisable but at a minimum requires prolonged

approximately 20% of patients with Down syndrome, syndr ome, and airway airway maneu maneuvers, vers, such as neck positioning during anesthesia for airway opening opening or intubation, intubation, may induce induce a serious cervical injury (C1-2 subluxation). This cervical spine instability is a contraindication for routine treatment until both the patient and the treatment risks are fully evaluat evaluated. ed. Sequel Sequelae ae to neuro neurologic logic injury are usually characterized by significant symptoms or declining neurologic function without other neurologic disorder.. Speci order Specific fic symptoms symptoms may include include a

patients is complicated by muscle weakness contributing to poor respiratory  function func tion.. Atr Atroph ophyy of the paraspina paraspinall muscles also leads to kyphoscoliosis (restrictive lung lung disease), which further restricts restricts respiratory function. function. Pulmonary function tests should should be considered considered as part of the preoperativ preop erativee assessment. assessment. Pat Patients ients with with functional vital capacities capacities < 35% 35% of normal are at increased risk. Muscle weakness weakness also contributes to obtunded laryngeal reflexes and an inability to clear tracheobronchial bronc hial secre secretions tions.. Pat Patients ients are at

observation prior to discharge.170

positive Babinski positive Babinski sign, sign, hyperac hyperactive tive deep tendon reflexes, ankle clonus, neck discomfort, and gait abnormalities. abnormalities. Down syndrome is associated with congenital heart disease in approximately  40% of its patie patients nts,, and cons conside iderat ration ion of  these abnormalities (endocardial cushion defect, defec t, ventri ventricular cular septal defect, defect, tetral tetralogy ogy of  Fallot, Fallo t, paten patentt ductus ductus arterio arteriosus, sus, and atrial septal defect) in conjunction with their primary care physician is mandatory prior to proceeding with a surgical procedure.

increased risk for aspiration secondary to the obtunded laryngeal reflexes and delayed gastric emptying. Patients with muscular dystrophy may  also have have cardiovascular cardiovascular disorders. disorders. These include degenerative cardiomyopathy cardiomyopathy,, cardiac arrhythmias, arrhythmias, and mitral mitral valve valve proprolapse. It is frequently difficult difficult to assess cardiovascular function in these patients because they are usually wheelchair-bound and not sufficiently sufficiently stressed. How However ever,, cardiac compromise must be considered, especially in in an older older individual. individual. Anest Anesthetic hetic

imately 10% were current illicit drug users. user s. Data from from 1999 1999 to 2001 identif identify  y  marijuana as the most popular abused drug, with a use approxi approximatin matingg 7% of this popula pop ulatio tion. n. Oth Other er abused abused subs substan tances ces included psychotherapeutic agents (approximately (appro ximately 3%), cocain cocainee (appro (approxiximately mate ly 0.5%), 0.5%), hall hallucino ucinogens gens (approxi (approxi-mately 1%), and inhalants (approximatel (approximately  y  1%). An adequate adequate history taking taking prior to anesthesia regarding substance use and abuse is therefore mandatory with all patients pati ents.. This history history allows allows for a safer safer

 Muscular Dystrophy  Dystrophy 

considerations must take into consideration the potential for underlying respiratory and cardiovascular cardiovascular disease. Succ Succiny inyll-

selection select ion of ane anesth stheti eticc agen agents ts and improved management of any perioperative complications.

Muscular dystrophy Muscular dystrophy is a group of diseases of genetic origin, characteriz characterized ed by the propro-

Substance Abuse  Substance abuse amongst children and teens has reached epidemic proportions, regar re gardle dless ss of soc socioe ioeco cono nomic mic stat status. us. In 2001 an estimated 15.9 million Americans ages 12 or older were current illicit drug users,, mean users meaning ing they they had used an illic illicit it drug during the month prior to the survey  interview.This interview. This estimate represents 7.1% of  the population ages 12 years old or older. Among youths youths ages 12 to 17 years, approx-

 

Pediatric Sedation

Alcohol Alcohol is the most commonly  used and abused substance among teenag tee nagers. ers. Mos Mostt alcoho alcoholl use by by US teenagers is in the form form of binge drinking. Most long-term long-term systemic effects of chronic alcohol abuse, including hepatic injury, injury, pancytopenia, and the neurotoxic neurotoxic effects

Amphetamine Amph Amphetam etamine, ine, a race racemic mic mixture of  β  β -phenyli -phenylisopropylami sopropylamine, ne, is an an indirect indir ect sympatho sympathomime mimetic tic drug. drug. It is a powerful CNS stimulant with peripheral α and β acti actions. ons. The CNS CNS mechanism mechanism of  of  amphetamine appears dependent on the local release of biogenic amines such such as

associated with ventricular hypertrophy, myocardial myocar dial depression, and cardiomyopacardiomyopathy.. Long-term use may also thy also lead to contraction band necrosis. necrosis. This phenomenon phenomenon is associated with hypermetabolic condition ti ons, s, su such ch as coc cocai aine ne abu abuse se,, hy hype perrthyro th yroidi idism, sm, and phe pheoc ochro hromoc mocyto ytoma ma

(seizures, Wernic (seizures, ernicke-K ke-Korsak orsakoff off syndr syndrome) ome) are not present in the pre-adult abuser. Nonet No nethele heless, ss, labo laborato ratory ry exam examinat ination ionss may reveal elevation of   γ -glutamyltrans-glutamyltransferase, fera se, whic which h is usually usually the first first liver liver enzyme to increase increase as a result result of heav heavy  y  ethanol ingestion. Hepatic damage owing to alcohol frequently results in an aspartate transaminase–to–alanine aminotransferase ratio > 1. A mean corpuscular volume > 100 is strong confirmatory evidencee of alco denc alcoholis holism. m. Aspiration risk is significantly 

norepinephrine from storage sites in nerve terminals. Acute amphetamine amphetamine use dramatically increases anesthetic requirement and has been implicated implicated in a case of severe intraoperative intracranial hypertension.171,172 Chronic amphetamine use is associated with a markedly diminished anesthetic requirement.173 This results from chronic stimulation stimulat ion of adrene adrenergic rgic nerve terminals in the peripheral nervous system and CNS that depletes CNS catecholamines. Refractory hypotension can result both intra-- and postop intra postoperati eratively vely,, requ requiring iring

resulting from continuous catecholamine concent con centration ration elevation elevation.. This condition condition predisposes the patient to dysrhythmias.175 Patients may also manifest neurologic effects. A decrease in seizure threshold threshold has been demonstrated in young adults. Ischemic cerebral vascular accidents may  result from the hypertensive crisis potentiated by the cerebral vasoconstriction v asoconstriction resulting from the increased serotonin levels. Respiratory complications associated with intranasal administration include sneezing, snee zing, snif sniffing, fing, and acut acutee rhini rhinitis. tis. Pul Pul--

increased in the chronic alcoholic as alcohol stimulates gastric acid secretion and delays gastric emptying time. In addition, addition, the alcoholic patient may consume alcohol the morning of of the procedure procedure to quell the the signs sig ns of wit withdr hdraw awal, al, thu thuss nega negatin tingg the the NPO status. Cardiovasc Cardiovascular ular changes assoassociated with chronic alcohol abuse result in alcoholic alcohol ic cardiomyopath cardiomyopathy, y, with resultant tachycardia and unexplained atrial or ventricular ectopy. Alcohol abuse influences the choice of anesthe anesthetic tic agents used in an outpatient outpatient

prompt pharmacologic intervention. There can be a diminished pressor response to ephedrine after chronic amphetamine amphetam ine use. use. This is is due to to catecatecholamine depletion in central and peripheral adrenergic neurons.

monary complications associated with inhalational administration include cocaine-induced cocaine-i nduced asthma, chroni chronicc cough, pulmona pulm onary ry edema, edema, and pneum pneumope operiricardium. Acute intoxicatio intoxication n may result in hypoxia owing to pulmonary vasculature vasoconstriction. High levels of cocaine may persist for 6 hours after nasal administration. administration. Elective anesthetic management should be deferred for at least 24 hours after the patient has last last used used cocaine. cocaine. Electro Electro-cardiographic monitoring is recomme recommendnd-

setting. Tolerance to anesthetic agents appears to develop in the chronic alcoholic. Altere Altered d liver function results results in an increased toxicity with anesthetic agents that undergo hepatic metaboli metabolism. sm. Prolonged activity and increased serum levels lev els of bot both h succin succinylc ylcho holin linee and local anesthetic agents are the result of de crea sed a ct iv it it y of pla sma choline cho linester sterase. ase. No Nondepo ndepolariz larizing ing paralytics are also prolonged in chronic alcohol abuse secondary to an increased level of ac acet etyl ylch chol olin ine. e. In Intr trav aven enou ouss agen agents ts

12- to 17-year-olds in the United States is approximately 0.8%.174 The medical effects from cocaine result from both acute intoxication as well as chro chronic nic use. CNS stim stimulati ulation, on, hype hyperrvigilance vigila nce,, anxie anxiety ty,, and agitation agitation are are common in the acutely intoxicated individual. Cardiovascular effects may include tachycard ca rdia ia,, ar arrh rhyt ythm hmia ias, s, hy hype pert rten ensi sion on,, an and d ischemia. Ischemic myocardial myocardial injury may  occur occ ur,, even in the the young young patie patient. nt. Thes Thesee effects result from from the inhibition inhibition of neural reup re upta take ke of do dopa pami mine ne,, se sero roto toni nin, n, an and d

ed in all patients owing to the potential for silentt ischemia silen ischemia and arrhyth arrhythmias. mias. Anes Anes-thetic management may include control of  preoperative anxiety with benzodiazepines. Consideratio Consideration n should be given given to avoiding adrenergic stimulants such as ketamine and epinephrine-containing local anesthetics.

should also include a benzodiazepine that compensates for the lack of   γ -aminobu-aminobutyric acid (GABA)-ergic stimulation.

tryptophan; increased adrenergic activity; and blockade blockade of the sodium sodium conductio conduction n channels. Chronic cocaine cocaine abuse has been

form. The psycholo psychological gical effects effects of MDMA include incl ude con confusi fusion, on, depr depressio ession, n, anxi anxiety ety,, sleepless sleep lessness, ness, drug craving, craving, and paranoia paranoia..

Cocaine Cocaine is an alkaloid derived from fro m the leaves leaves of a South Ame America rican n shrub.. The drug is snorted shrub snorted (intranasa (intranasal), l), inje in ject cted ed (int (intra rave veno nous) us),, or smok smoked ed (inhaled). Its administration administration provides an intense inte nse euphoria. euphoria. Coc Cocaine aine use amongst amongst

“Ecstasy” 3,4-Methylenedioxymethamphetamine (MDMA) is a stimulant that has psychedelic effects that can last for 4 to 6 hours and is usually taken orally in pill

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Adverse physical effects include muscle tension, involun involuntary tary teeth clenchin clenching, g, nausea, blurr blurred ed vision vision,, feel feeling ing fain faint, t, trem tremors, ors, rapid rapi d eye moveme movement, nt, and sweatin sweatingg or chills. There is also an added risk involved involved with MDMA ingestion by people with circulatory problems or heart disease because

Inhalational Substances Inhalation substance abuse is a problem usually associated with young patients including preteens. preteens. The 1997 Monitoring the Future nationwide survey reported that inhalant use is most common in the the eighth grade, in which 5.6% of students used inhalants on on a past-month past-month

nia, sev nia, severe ere dep depres ressio sion). n). It is is diffic difficult ult to to determine the extent extent and mechanism of of the LSD involvement involvement in these illnesses. Perioperative anesthetic practice involves recognition of the potential potential psychiatric psychiatric effects effects of  LSD on patients patients and avoidanc avoidancee of pote potenntially aggravating agents.

of MDMA MDMA’s ’s ability to to increase heart heart rate and blood pressure. In 2001 an estimated 8.1 million (3.6%) of Americans ages ages 12 or older had tried ecstasy at least once in their lifetime. The princ principl iplee consti constitue tuent nt of ecs ecstas tasy  y  (MDMA) can produce robust deleterious effects on serotonergic functioning in animals, including seroton serotonin in depletion depletion and the degeneration of seroton serotonergic ergic nerve terminals.176 Although MDMA has been characterized characteriz ed as a hallucinogenic amphetamine because of its structural structural similarity 

basis and 11.8% on a past-year basis.179 They may may present present with photophobi photophobia, a, eye irri ir rita tati tion on,, di dipl plop opia ia,, ti tinn nnit itus us,, sn snee eezi zing ng,, anorex ano rexia, ia, che chest st pain pain,, and dys dysrhy rhythm thmia. ia. Before administering anesthesia one must take into considerat consideration ion hepatic, hepatic, renal, bone marrow,, and other organ pathology marrow pathology caused by halogenated and impure chemicals. Lysergic Acid Diethylamide Approximatelyy 1% of 16-ye matel 16-year-o ar-olds lds in the United United States used lysergic acid diethylamide (LSD) in 2001. LSD LSD,, also known as “acid, “acid,” is

Marijuana Marijuana is the most commonly used nonalcohol illicit drug for people < 18 years years old. In 2001 it was used used by 76% 76% of of curren currentt illicit illicit drug users. users. Approximately Appro ximately 56% of of current illicit illicit drug users consumed only only marijuana, 20% used marijuana and another another illicit drug, and the remaining 24% used an illicit drug but not marijuana in the past month. Patien Patients ts who use marijuana may present with anxiety, panic attacks, attacks, and sympathetic discharge. discharge. Adverse Adv erse effects effects of marij marijuana uana include include

to mescaline mescaline and and amphetamine, amphetamine, it rarely  rarely  induces hallucinatory hallucinatory experiences, nor is it as potent a psychostimulant as amphetamine. Whether neuroto neurotoxicity xicity also occurs occurs in humans is unknown, unknown, but emerging evidence indicates that repeated ecstasy exposure results in performance decrements in neurocognitive neuroco gnitive function, function, which may be a manifestation manifestatio n of neuroto neurotoxicity xicity..177,178 Most ecstasy tablets contain MDMA; other commonly identified ingredients incl in clude ude ke ketam tamin ine, e, met methy hylen lened edio ioxy xy-ampheta amph etamin mine, e, amph ampheta etamin mine, e, dext dextrom rometh eth--

odorless and colorless, odorless colorless, has a slightly bitter taste,, and is usually taste usually taken taken by mouth. mouth. Often LSD is added to absorbent paper such as blotter paper and divided into small decorated squares, with each square representrepresenting one dose. dose. The effects effects of LSD are unpreunpredictable.. They depend on the amount dictable take ta ken; n; th thee user’ user’ss perso persona nali lity ty,, mo mood od,, an and d expecta expe ctation tions; s; and the surrou surroundin ndings gs in which the the drug is used. used. Usu Usually ally the user user feels the the first effects effects of the drug 30 to to 90 minutes after taking it. Physical manifestationss inc tion include lude mydriasis mydriasis,, hype hyperthe rthermia rmia,,

immunodeficiency and upper airway  hyperr hyp erreac eactiv tivity ity.. Cas Cases es of of lary laryngo ngospa spasms sms within with in 36 hours hours of of its use use have have been reported.180 A β2-adrenergic agonist such as albuterol may be considered to treat this increased airway airway reactivity. reactivity. Other perioperative considerations include that mari juana potentiates opioid-induc opioid-induced ed respiratory depre depression ssion,, and barbitur barbiturate ate and ketamine recovery time may be prolonged. Myocardial Myo cardial depression can occur, occur, and the threshold for sympathomimetic-induced dysrhythmias is lowered.

orphan orph an,, and combinatio combinations ns of these drugs. Some tablets contain inert ingredients, whereas others contain phencyclidine hydrochloride hydrochlo ride (PCP). Perioperative management may  involve addressing several complications, the most common being syndrome of  inappropriate antidiuretic hormone, and hyperthermia. hyperth ermia. Other less commo common n but well-known potential complications include tachy tachycardia, cardia, agitation, and nausea and vomiting. vomiting. Monito Monitoring ring for the stigmata of hypo hyponatr natremia emia and hyperth hyperthermia ermia

tachyca tachy card rdia ia,, hy hyper perte tensi nsion on,, dia diapho phore resis sis,, anorexia, anor exia, and tremors. tremors. Extre Extreme me emotiona emotionall variability variabi lity may occur, occur, with extreme extreme delusions and visual hallucinations. LSD effects effects are pro prolon longed, ged, typic typically ally last lasting ing for > 12 hours. “Flash “Flashbacks backs”” with auditory auditory and visual hallucinations may recur suddenly  without reuse reuse of the drug and may may occur occur within a few days or more than a year after LSD use. Flashbacks usually occur occur in people who have used hallucinogens chronically or who have an underlying personality problem. Ho Howev wever er,, oth otherwis erwisee heal healthy thy peo people ple

PCP PCP is a dissociative anesthetic that originally was synthesized for intraveno intravenous us use.. Be use Becau cause se of its post postope operat rativ ivee emeremergencee rea genc reactio ctions ns (ie, hall hallucin ucinatio ations, ns, prolonged long ed abnormal abnormal level of con conscio sciousne usness, ss, agitation agita tion), ), it fell out out of fav favor or,, and its use as an anesthetic in humans was discontin discontinued ued in 1963. PCP subsequently subsequently emerged emerged as an orall drug ora drug of abu abuse. se. PC PCP P is a commo commonly  nly  abused street drug that is sold under many  different names and in various forms. It may be sold on the street in tablet or cap-

supplements a well-performed preoperative history to determine which patients are at risk.

who use LSD may also experience flashbacks. bac ks. Lon Long-t g-term erm effec effects ts of chr chron onic ic LSD LSD include psychiatric disorders (schizophre-

sule form, form, as a powder powder,, or as a solution solution.. The PCP content in each form differs widely,, commonly from widely from 10 to 30%. “Angel

 

Pediatric Sedation

dust,” the powdered form of dust,” of PCP PCP,, generally has a higher PCP conten content, t, occasion occasionally  ally  reachingg 100%. Angel dust may be sniffed, reachin smoked, smok ed, inge ingested, sted, or injecte injected d IV. IV. Pe Percut rcutaaneous absorption also has been reported to occur in individuals handling PCP (eg, law la w enforc enforceme ement nt offic officers ers). ). Smo Smokin kingg remains remai ns the the desir desired ed metho method d of use use;; the substance commonly is sprinkled onto dried dri ed leaf leaf mat materi erial al (eg, mar mariju ijuan ana, a, to tobac bac-co, oregano oregano,, mint) and and then smoked. Perioperative anesthetic considerations include its sympathomimetic effects, similar to to its congene congener, r, ketamine ketamine,, with the potential poten tial for tachycar tachycardia, dia, tach tachyarrh yarrhythythmias, and a true hypertensive hypertensive emergency emergency.. Maintaining normotension and avoiding sympathomimetics, sympathomimetic s, which may exacerbate exacerbate PCP’ss effects, are the standard for PCP’ for anesthetic management.

Summary  Ambulatory anesthesia in the pediatric patient can be safely achieved in the oral and maxillofacial maxillofacial surgery surgery office. office. The surgeon has an array of technique techniquess that are are available. A technique technique has to to be selected selected that is approp appropriate riate for for the patient, patient, the planned procedure, procedure, and the specific office.

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