Premedication Pain managment

1. PremedicationPain managment

2. Measurement of pain in children • Observer-based techniques which are useful in pre-verbal children, blood pressure, crying, movement, agitation and verbal expression/body language. • Self-reporting of pain is valid in children over 4–5 years of age. • Older children and teenagers can use a normal visual analogue scale of 1–10. • Mentaly handicaped children - difficult to assess - unusualchanges in behaviour

3. Analgesia prior to procedures (pre-emptive analgesia) • ensure adequate systemic and/or local analgesiaprior to the commencement of a procedure • Appropriate time for absorption and effect should be allowed. • A stronger analgesic may be required for the procedure with regular simpleanalgesics for the postoperative period.

4. Routes of administration • Per os - is the preferred route of administration in children. • absorption formost analgesics is generally rapid – within 30min • liquid vs.tablets in younger children, taste - can help greatly with compliance • Per rectum - in a child who is fasting or nottolerating oral fluids. • peak levels are usually much longer (paracetamol90–120 min) - not used in theimmunocompromised child due to the risk of infection • Intranasal or sublingual - as an alternative • Intramuscularinjection should be avoided in children • In obese children, the dosage given should be based on ideal body weight

6. Paracetamol • pre-op 20 mg / kg po (syrup) • Post-op 15 mg / kg po á 6 hours. • (30 mg / kg as a single dose rectally) maximum 24-hour dose 90mg/kg, followed by 50 mg / kg / d! • from 3.months of age • ! Watch out in hepatopathy • Useful as a pre-emptive analgesic • No effect on bleeding • IVparacetamol (PERFALGAN)in hospitalised

7. NSAID - ibuprofen • Pre-op - ibuprofen 10mg/kg p.o. (syrup) • Post-op – if needed ibuprofen 5 mg/kg á 6-8 hod. p.o. • Effective alone after oral and dental procedures. • Can be used in conjunction with paracetamol. • Have an opioid-sparing effect. • Increase bleeding time due to inhibition of platelet aggregation. • Useful analgesic once haemostasis has occurred. • Best given if tolerating food and drink. • Can be used in infants over 3 (some authors 6)months of age.

8. Non-steroidal anti-infl ammatory drugs (NSAIDs) NSAIDs are contraindicated in children with: • Bleeding or coagulopathies. • Renal disease. • Haematologicalmalignancies, who may have or develop thrombocytopenia. • Asthma, especially if they are sensitive to asthma, steroid-dependent or havecoexisting nasal polyps.

9. Sedation in paediatric dentistry • The choice of a particular technique, sedative agent and route of delivery • children’s responses are more unpredictable than adults - easily over-sedated Anatomical differences between the adult and the paediatric airways include: • Children have a relatively larger tongue and epiglottis. • Possible presence of large tonsillar/adenoid mass • The mandible is less developed and retrognathic in children. • Children have smaller lung capacity and reserve.

10. Patient assessment • Medical and dental history (including medications taken). • Patient medical status (American Society of Anaesthesiologists (ASA) classifi cation). • History of recent respiratory symptoms or infections. • Assessment of the airway to determine suitability for conscious sedation or general anaesthesia. • Fasting status • Procedure being performed • Age • Weight • Parent factors

11. Inhalation sedation- nitrousoxide sedation • Anxiolytic and mild analgesic effect • Anxiousbut cooperating children • Age - 4 years Benefits • safe and relatively easy technique. • light sedation. • rapid onset (2-3min) and readily reversible with a short recovery time (10-15min) • Entonox- titre fixed-N0 50%, 50% O2 • requires onlyclinical monitoring

12. Contraindications • Severepsychiatric disorders , mentaly handicaped • Obstructive pulmonary disease • Chronic obstructive airway disease • Communication problems • Uncooperating patients • Pregnancy • Acute respiratory tract infections Complications • nausea, vomiting • headache

13. Course of performance • healthy child(no colds, cough and / or fever), • not fasting, • Entonox- inhalation using a face mask or mouthpiece. • Maximum effect starts usually after 2-5min of uninterrupted inhalation • Inhalation of Entonox continued intermittently throughout the performance (application of local anesthesia, tooth extraction, surgery). • After treatment - child is kept under supervision in a room of about 5 to 10 minutes or until his attention and motor coordination are sufficiently restored

14. Conscious sedation • patient who isawake, responsive and able to communicate • maintenance of protective reflexes • ! conscious sedation, deep sedation and/or general anaesthesiais a continuum • Pulse oximetry • Age and size-appropriate equipment and medications for resuscitation

15. Oral sedation Premedication • Benzodiazepines (e.g. midazolam) • Potentiated sedation– ANESTEZIOLOGIST • Chloral hydrate • Hydroxyzine • Promethazine • Ketamine

16. Midazolam - Dormicum • short-acting benzodiazepine • rapid patient recovery - extra sleep 2-3 hours • dosage ranges from 0.3 mg - 0.7 mg / kg • We 0.5 mg / kg • P.o.Dormicum tablets 7.5 mg or Midazolam 1 ml amp • effects: • Sedative, hypnotic, anxiolytic, anterograde amnesia, myorelaxant

17. Course of performance • The child must be healthy (no fever, cough, fever), • Fasting for min. 3 hours (6hrs). • With parent - short-term hospitalization, • midazolam administered as a solution or tablets (0.5 mg/kg) • under the supervision of accompanying person on a bed in sleep-room. • onset of effect of midazolam - within20-45 minutes the followed by dental procedures (tooth extraction / s, tooth decay treatment, surgery) • Recovery period 2-3hrs - under the supervision of accompanying person on a bed in sleep-room.

18. Midazolam • drugs given orally cannot be titratedaccurately • hepatic metabolism • an overdose cannot be easily reversed • oral sedation requires cooperation from thechild to ingest the medication • Never re-dose • Per rectum - more reliable and controllableabsorption, but requires cooperation, bad compliance • Intranasal - whether the drug is absorbed directly from the blood stream or thereis direct uptake to the central nervous system, requires a higher level of training and monitoring

19. Midazolam • Intravenous sedation • requires a highly trained team • specialist anaesthetist • monitoring, adequate facilitiesand recovery options • controllable andmay be readily reversible • inappropriate form of drug administration in extremely anxious children • IV sedation - in a hospital environment oraccredited dentalsurgeries

20. Suitable procedures for midazolam sedation • Short procedures that require approximately 30 minutes duration. • Primary teeth extractions or up to two permanent molars. • 1–2 quadrants of restorative dentistry. • Short surgical procedures with good access in the mouth. not suitable forsedation • 3–4 quadrants of restorative dentistry • Extractions of permanent molars in each quadrant (invasive procedure and bleedingfrom all four quadrants make airway management more difficult). • Obese children • Parents who may not provide adequate care to the child postoperatively.

21. Midazolam - complications • In rare cases, complications may occur in the form of so-called paradoxical reactions (manifested as tearfulness, hyperactivity, agitation, refusal to aggressive behavior) • or vomiting. Symptoms of midazolam overdose can include: • Ataxia • Dysarthria • Nystagmus • Slurred speech • Somnolence (difficulty staying awake) • Mental confusion • Hypotension • Respiratory arrest • Vasomotor collapse

22. Discharge criteria after sedation • Self-maintenance of airway. • Easily rousable and able to converse. • No ataxia, can walk properly. • Tolerating oral fl uids. • Discharge in the care of a responsible adult with appropriate information about • after-hours contact if a problem arises.