Ass~sment of the Effects of 2 Sedation Regimens on Cardiopulmonary Parameters in Pediatric Dental Patients: A Retrospective Study

Purpose: The purpose of this study was to evaluate the cardiopulmonary effects of 2 sedation regimens during treatment: (1) oral meperidine and hydroxyzine with nitrous oxide (N20); and (2) oral diazepam and hydroxysine, submucosal meperidine, and NZO. Nitrous oxide was tapered to oxygen (0) only 10 minutes following submucosal meperidine administration. Methods: Sixty-two children were evaluated who met the following criteria (1) history of uncooperative behavion (2) ASA I or II; (3) norhing ro eat or drink &er midnight the night before the appoin[men~ (4) an initial/reealI exam prior to the sedation appointment; and (4) parients who met the American Academy of Pediatric Dentistry guidelines for sedarion. Regimens I and 1I included 32 and 30 patients, respectively. A single clinician treated all patients. A Criticare monitor recorded the following at 5-minute intervals: (1) 02 saturation; (2) respiratory titei (3) heart ratq (4) systolic and diastolic blood pressures; (5) end tidal carbon dioxide eoncenrration; and (6) mean arterial blood pressure. Rasdti: The t test indicated significant differences between the 2 regimens fon (1) healt rate (2) systolic blood pressure and (3) diastolic blood pressure (regimen 11had higher values).Using the general linear model,no significant differences were found. All cardiopulmonary parsrnecers were within normal limits. Conclusion: Regimens I and 11had similar cardiopulmonary effects, (Pediatr Dent 2006; 28:350-356) -OSU.5S: CHILOREN, SEOATSON, CA2U21OPULMONARY Rectivedsepternber 262005 Revition Accrpted Februa~ 24,2006 Sedation has been widely employed by pediatric dentists in the management of uncooperative patients who need extensive dentai treatment. This procedure can: 1. reduce anxie~ 2. provide analgesia and, thus 3. allow performance of surgical procedures that otherwise would be stress ful.’ The cooperation of a child depends on his or her chronological and developmental age. Developmentally delayed children and those younger than 6 years of age ofien require a deep level of sedation to gain their cooperation.2 According to the American Academy of Pediatric Dentistry’s (AAPD) Clinical Guideline on the Elective Use of Minimal, Moderate, and Deep Sedation (levels 3 and 4), deep sedation is defined as a “drug-induced depression of consciousness during which patients cannot be easily aroused, but may respond purposeklly following repeated ‘Dr, Cben is ciinicai a.rrirtantprofissor and ‘Dx Seyboti is clinical arsociateprofissoc Department of Pcdiawic Dentsiq The Universi~ ofT~~. Dental +xb atHowton, Homton, Teu; BDE y~i i$ ~ pedtatrtc htr~t In private practice, Austin, Zx, Correspond with DE Chen ~t jung-wei.cben@utb. cnrc,edu verbal or painti stimdarion.”~ Thus, these deve[opment~y delayedand younger tilldren ate especially vulnerable to the adverse effects of sedatives on respiratory drive, loss of protective reflexes, and airway blocitage.2 Since deep sedation may occur aker administration “of sedatives in any child, proper equipment and practitioner’s skills are essential for safe management of sedated children.2 When selecting a drug regimen, the patient’s safety, as well as the effectiveness of the sedation mediation, must be considered. The safety of patients undergoing sedation has become of increased concern in recent years.4.5Reports of deaths or serious long-term injuries following sedation have raised awareness of potential adverse events associated with sedation and increased attention to the safety and close monitoring of sedated children.4 The American Academy of Pediatrics in 1992 emphasized that the use of N20 with other sedative agents, narcotics, or other depressant drugs could quickly cause a state of deep sedation or general anesthesia and requires the level of “deep sedation” monitoring.b Nitrous oxide (N20) gas in combination with other sedative agents is often used in pediatric dentistry to manage uncooperative children.7 Due to the ea,seof administration of sedative medications and the experience of pediarric den350 Chen et al. . Cardiopu[mona~ Efectr of Sehrion Re~”men~ Pedtimc Denti,r~ -28:42006 tists with oral sedation, this technique is the most frequently employed sedation route used by pediatric dentists.s Cot< et al investigated adverse sedation events in pediatric patients and concluded that there was no relationship between the outcome of the sedation and the drug class or route of administration of the medications.q Negative outcomes were associated with: 1, drug overdos~ 2. drug combinations and interactions: 3. the use of 3 or more sedative agents; and 4. administration of N20 in combination with any other class of sedating medication.g Cot4 et al concluded that the cause of the practitioner’s failure to rescue the patient was eithen 1. a delay in recognizing the severity of the adverse even~ or 2. lack of experience of the practitioners in CPR and airway management.’” Selbestl’ reported that the analysis done by Cotd et al’” had shortcomings, including possible poor and incomplete documentation in the clinical records, a small number of cases reviewed (11 8 cases), and old cases dating back to 1969. The author emphasized that evaluating only the adverse events, not the successful cases, creates a distorted view for practitioners and discourages the use of sedative agents. Peiia et al analyzed 1,180 sedation cases using different types of medications performed in a pediatric emergency department by trained nonanesthesiologisr personnel.5 The dosage of medications used was according to published guidelines. The study revealed that adverse events—such as oxygen (Oz) desaturation requiring intervention, paradoxical reactions, emesis, apnea, laryngospasm, and bradycardia-occurred in over 2% of the cases. These events were minor, transient, and easily managed. Bryan studied the eficacy of NzO/Ozinhalation sedation in pedlarric dentistry and found NZO to be a very successful rool in rhe clinical management of children undergoing dental treatment.’2 Treatment was completed as planned in 84% of children who were mostly between 5 and 8 years old using N,0/02, Also, treatment was successhlly completed in 38 out of 39 children (97°/0)who previously were treated under general anesth~ia. Therefore, a second general anesthesia procedure for rhe purpose ofdenral treatment was avoided. Litman et al showed thar the addition of 30V0 or 50% NZO to TO mg/kg of oral chloral hydrate ofien caused decreases in ventilation and resulted in deep sedation in children.’ The addition of 500?0NIO produced a state resembling general anesthesia in 1 of 32 patients. There was, howeve~,no physical stimulation of this study’s patients. Song et al studied the effect of oral vs submucosal administration of meperidine on rhe behavior of the pediarric parient.’3 The study found no difference in efficacy regarding improvement of behavior between oral administration of meperidine ( I mg/lb) plus promethazine (0.5 mg/lb) and 50% N20 vs submucosd atilnistration of meperidtne (0.5 mg/lb) and oral promethazine (0.5 mg/[b) plus 50% N O. The authors stated that because first pass metabolism o~oral meperidine inactivates approximately 50’?! of the drug, this agent’s plasma level in the 2 drug regimens was expected to be similar. Hasty er al evaluated 2 drug regimens to determine if the addition of meperidine wodd improve patient behavior and increase Ihe prevalence of respiratory compromise in children.’4 Regimen I included 50 mg/kg of oral chloral hydrate with 25 mg of hydroxyzine plus 1.5 mg/kg of meperidine. Regimen 11 included 50 mg/kg ofchloral hydrate plus 25 mg hydroxyzine. In this study, rhe addition of meperidine resulted in a significant improvement in patient behavior during operative dental procedures. Both regimens resulted in little respiratory compromise and apnea in patients. The most concerning adverse effect of sedation is respiratory depression and its potentially long-term consequences,4“f Respiratory compromise can eventually lead to hypoxemia and predispose the patient to more serious conditions. 1t Sedative agents can potentiare the respiratory depression property of narcotics. Local anesthesia can exacerbate this condition, “15 Pulse oximerry is rourinely used to monitor the Oz saturation level of patients during sedarion. It provides a reliable estimare of Oz saturation of the patient. ‘GDetection of airway obstruction and apnea based on reduction in O* saturation rate alone, however, especially when supplemental 02 is administered, can be a delayed process. Undetected apnea or hypovenrilation may lead to hypercarbia and acidosis--which, by the time of detection by pulse oximetry alone, may be at a significant level. ‘GApnea can accurately be detected by capnography,which is not fleeted by supplemental Oz flow rate.’t The purpose of the current srudy was to evaluate the cardiopulmonary effects of 2 different conscious sedation regimens. Regimen I consisted of oral meperidine and hydroxyzine with the use of nitrous oxide (NZO), and regimen II consisted of oral dlazepam and hydroxyzine with submucosal meperidine and limited NZO use.