deep sedation with sevoflurane insufflat”>Case Report

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American Journal of Emergency Medicine

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American Journal of Emergency Medicine 31 (2013) 894.e1-894.e3

Deep sedation with sevoflurane insufflated via a nasal cannula in uncooperative child undergoing the repair of Dental injury

Abstract

Sevoflurane, a potent volatile anesthetic, has been attempted to be used for procedural sedation. Because of lack of a commercially available sedation apparatus for sevoflurane administration, anes- thetic gas delivery apparatus should be connected to general anesthetic machine for delivering sevoflurane gas. In this case, deep sedation was maintained during treatment of dental injuries involving the upper lip and incisor by sevoflurane insufflations via a nasal cannula. Especially, this may be advantageous in treating dental injuries involving upper lip and maxillary anterior teeth because the treatment is not disturbed during sevoflurane insuffla- tions via a nasal cannula.

Clinicians frequently encounter difficulties in performing painful procedures for uncooperative pediatric patients. Oral agents, for example, Chloral hydrate, have been widely used in these situations. However, recovery profiles such as its long onset time are not relevant for short-term procedural sedation. Sevoflurane has been widely used for pediatric general anesthesia. Recently, several attempts have been intended to sedate pediatric patients rather than to use general anesthesia. We previously reported a case of deep sedation with sevoflurane inhaled via a nasal hood for short-term dental treatment [1]. However, nasalhooditselfmaybeanobstacleintreatingtheinjuries to upper lip and maxillary anterior teeth due to its pressure against these sites. Sedation by sevoflurane insufflation via nasal cannula has been described for infants presenting for magnetic resonance imaging (MRI), not a painful radiologic procedure [2]. Procedures for dental problems, especially those involving upper lip and incisor, can be easily performed with the nasal cannula. Here, we report a case of deep sedation by sevoflurane insufflation via nasal cannula to treat dental traumatic lesion in uncooperative pediatric patient.

A 3-year-old boy was admitted to hospital for repairing the upper incisor fracture with upper lip laceration. He accidentally fell down to the ground. His anterior tooth was completely fractured with a 0.5-cm laceration of upper lip. Because his cooperation was poor, we planned to have a restorative treatment and to make a suture repair under deep sedation.

As soon as we transferred him to dental chair, we administered 8 vol% inspired sevoflurane gas to him using a full facial mask. After achieving loss of consciousness, we placed a nasal cannula (HUDSON RCI: Teleflex, NC, USA) (Fig. 1) incorporated with capnography line into his nostril expecting that nasal cannula for delivering sevoflurane gas does not interfere with repairing laceration of the upper lip as well as the fractured anterior teeth. The nasal cannula was first connected to an anesthesia machine (Aestiva/5; Datex Ohmeda, WI,

USA). Then, we delivered sevoflurane anesthetic gas to him through the nasal cannula (Fig. 2). We adjusted sevoflurane vaporizer setting and delivered 100% oxygen at gas flow of 2 L/min to him. We monitored end-tidal sevoflurane concentration and his respiration through capnography line incorporating within the nasal cannula during sevoflurane insufflation. We adjusted inspired sevoflurane gas concentration to maintain end-tidal sevoflurane concentration in the range of 1 to 1.5 vol% as much as possible.

End-tidal sevoflurane concentration was disproportionately low compared with inspired sevoflurane concentration. The restoration of the fractured incisor and the upper lip laceration was successfully performed under the sedation using sevoflurane insufflation. After completion of the dental treatment, sevoflurane was discontinued. He gained his consciousness less than 5 minutes after discontinuation of sevoflurane. Hewasdischargedfrom hospitalwithoutany complications. Sevoflurane has been widely used in the arena of pediatric anesthesia [3]. Its fast onset and offset are suitable in the ambulatory anesthesia. Considering that most of dental treatments have been performed in the ambulatory setting, sevoflurane can be effectively used in dental area. Because of its nonpungent property, sevoflurane is widely used for volatile anesthetic induction and maintenance anesthesia [4]. It has more advantages when anesthetizing pediatric patients, especially in cases where intravenous cannulation is difficult. Recently, sevoflurane, usually intended to be used for general anesthesia, has been used for procedural sedation in uncooperative pediatric patients [1,2]. A delivery apparatus connecting with general anesthesia machine is

Fig. 1. HUDSON RCI nasal cannula with gas sampling line. Exhaled carbon dioxide is continuously aspirated via gas sampling line. A, Nasal prong. B, Gas sampling line.

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radiologic examination. This sedation technique described in this case has advantages in treating dental problems, especially those involving upper lip and incisors.

We are not certain of the inspired sevoflurane concentration to achieve the desired level of sedation because of insufficient number of case. Interestingly, in this case, the end-tidal sevoflurane concentra- tion was much lower than the inspired gas concentration during most of the dental treatments. We delivered sevoflurane gas at a concentration more than 3 to 4 vol%, nearly equivalent to 1.5 minimal alveolar concentration value [7], for maintaining deep sedation. End- tidal sevoflurane concentration was in the range of 1.2 to 1.7 vol%, whereas he received 3 to 4 vol% sevoflurane. It may be speculated that entrapped air during sevoflurane inhalation may dilute inhaled sevoflurane gas concentration. Increased mouth breathing may further dilute inspired sevoflurane gas. Therefore, it should be kept in mind that inspired sevoflurane concentration is adjusted to maintain end-tidal sevoflurane concentration in keeping an appro- priate level of sedation, although a further study should be warranted to investigate the dynamic relationship between end-tidal sevoflur- ane concentration and sedation depth.

In addition, respiration monitoring is a core element in monitoring patients, especially during deep sedation [8]. Capnography is known to be the most sensitive monitor for respiration monitoring. To deliver sevoflurane gas in this case, we used the nasal cannula incorporated

Fig. 2. Nasal cannula is inserted into both nostril. Sevoflurane gas is delivered to the patient.

needed to make sedation with sevoflurane possible because of the lack of commercially available sevoflurane sedation equipment. In the field of dentistry, either nasal hood or nasal cannula, which can leave the oral cavity for easy access to dental treatment, may be used to administer sevoflurane gas for inhalation sedation.

In a previous report that we described, we used a nasal hood to deliver sevoflurane anesthetic gas for sedating uncooperative pediat- ric patients for short-term Dental procedures [1]. The patients tolerated the placement of a nasal hood during dental treatment. However, theoretically, nasal hood itself may be an obstacle in treating the lesions involving upper lip and maxillary anterior teeth. In this case, we chose a nasal cannula, not a nasal hood to administer sevoflurane gas because the treatment for the traumatic sites involving upper lip accompanied by crown fractured incisor was considered. Indeed, nasal cannula, firmly secured, did not interfere with dental treatment. It seems to be beneficial to use sevoflurane insufflations technique with nasal cannula to sedate uncooperative pediatric patients undergoing dental treatment at these sites.

Sevoflurane sedation delivered via nasal cannula was first described in a preliminary report described by Sury et al [2]. Infants for MRI scanning were sedated with sevoflurane insufflations via nasal cannula. For MRI scanning, a hypnotic component of sedation, not an analgesic component, needs only to be considered for successful sedation because it is not a painful procedure. However, analgesic component should be considered for painful procedural sedation. Clinically, ketamine is a widely used sedative for short-term painful procedure in children [5,6]. However, ketamine is related to negative behavioral problems after procedural sedation. Ketamine also has a disadvantage for short-term procedural sedation due to prolonged recovery. In our case, compliance to treatment was good during sevoflurane sedation. They did not violently move even in the course of painful procedure. Physical restraint was rarely applied during the treatment. Moreover, painful intravenous cannulation and Intramuscular injection were not needed for sedation. In addition, recovery from sevoflurane inhalation sedation was fast (nearly 3-5 minutes). Therefore, we recommend sevoflurane insufflation tech- nique using nasal cannula as one of the sedation options in managing uncooperative children for painful procedure, not only for nonpainful

with capnography line, which also enabled us to monitor respiration

during the sedation. Using capnography, we monitored the adequacy of the respiration and the end-tidal sevoflurane concentrations, so that we could adjust the settings of sevoflurane vaporizer to achieve the desired level of sedation instead of preventing from developing into anesthesia.

Theoretically, the nasal cannula can be displaced from the nostrils if adhesives fail. If this happens, inspired sevoflurane concentration may be lowered enough for patients to be arousable during treatment. In our cases, we placed the nasal cannula on both cheeks with strong adhesives. Its dislodgment did not happen during the dental treatment without any significant reduction of the inspired sevo- flurane concentration. However, the patients may be arousable with sudden drop of inspired sevoflurane concentration unless the nasal cannula is firmed secured to the nostrils.

In this case, the sevoflurane insufflation technique via nasal cannula was successfully performed to sedate uncooperative children without other sedatives. Deep sedation by sevoflurane insufflation may be used as a practical alternative method in the field of pediatric dentistry, although further experience may be needed to determine its clinical usefulness.

Seung-Oh Kim MD, PhD

Department of Dental Anesthesiology

Dankook University Cheonan-Si, Chungcheongnam-do

Republic of Korea

Young-Jae Kim DDS, PhD

Department of Pediatric Dentistry

School of Dentistry Seoul National University Seoul, Republic of Korea Yong-Seo Koo MD Department of Neurology

Korea University College of Medicine

Seoul, Republic of Korea Neurology Department

Jeju Medical Center of Jeju Special Self-Governing Province

Jeju Special Self-Governing Province

Republic of Korea

S-O. Kim et al. / American Journal of Emergency Medicine 31 (2013) 894.e1-894.e3 894.e3

Teo Jeon Shin MD, PhD

Department of Pediatric Dentistry

School of Dentistry Seoul National University Seoul, Republic of Korea

E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2013.01.008

References

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