In-Office IV Sedation

This procedure is performed in our office by a Certified Registered Nurse Anesthetist, Amy Koons, CRNA or one of Specialty Anesthesia Services associates. She is a board certified by the National Board of Certified Registered Nurse Anesthetists (NBCRNA).

As with all procedures at our office,

SAFETY IS OUR NUMBER ONE PRIORITY WITH YOUR CHILD!!

1. SAFETY FIRST! 

As an added safety precaution and prior to this procedure, we have your child see a primary care practitioner for a health and physical update exam.  In accordance with Louisiana State Law, this must be done within 30 days of the anesthesia procedure.  We will send this form to the doctor of your choosing, and they will send this form directly back to our office.  This allows the primary care practitioner and us to identify and eliminate any potential risk factors that your child may have, so that we can provide safe and successful anesthesia and dental treatment for your child.  That being said, we are always prepared for emergencies by having the state required emergency resuscitative medications and equipment in our office. 

Although extremely rare, Amy Koons, CRNA, and Nathan Burns, DMD, are prepared to handle any emergencies that may arise during your child’s procedure.  Amy Koons, CRNA holds emergency training certifications in the American Heart Association Basic Life Support (BLS, CPR), Advanced Cardiac Life Support (ACLS), and Pediatric Advanced Life Support (PALS).  Amy Koons, CRNA, has undergone extensive specialty training in sedations during her 4-year nursing school and her 3-year advanced practice nursing residency.  Her is licensed by the Louisiana State Board of Nursing and holds an Advanced Practice Nursing License from the Louisiana State Board of Nursing as well. Amy Koonshas practiced anesthesia for over 20 years, including working for St. Jude’s Children’s Research Hospital.

Nathan Burns, DMD, holds emergency training certifications in the American Heart Association Basic Life Support (BLS, CPR) and Pediatric Advanced Life Support (PALS).  These certifications require both of them to attend courses every 2 years that are taught by a licensed instructor and pass a hands-on test and a written test. Dr. Nathan has undergone extensive specialty training in conscious sedation during his 2-year pediatric dental residency and maintains an active Pediatric ModerateSedation License, as issued by the Louisiana State Board of Dentistry.  Dr. Nathan has been practicing for over 15 years. 

All of our dental assistants are also certified by the American Heart Association in Basic Life Support (BLS, CPR) and will be helping Amy Koons, CRNA or one of her associates, constantly monitor your child with the required monitoring equipment to ensure their safety.  She will be administering the IV drugs and monitoring your child the entire time, while Dr. Nathan or the associate dentist will do the dental treatment.   Safety is our main concern and is taken very seriously at our office. We will be happy to answer any questions you may have about this or any procedures we do at our office.

If at any time during the procedure, your child becomes dangerously combative or we cannot sedate your child comfortably and safely with the maximum allowable medication, we will stop the procedure.  We may then have to complete their dental treatment completed in a hospital setting.  Of course, your options will be discussed with you by Dr. Nathan or the associate dentist. 

If at any time, we feel that your child’s safety is in danger, we will call 911 for immediate medical assistance.  

2.  THE IV SEDATION TECHNIQUE.

Intravenous moderate sedation, also called monitored anesthesia care (MAC) and intravenous deep sedation, is a form of anesthesia that is available to be performed in our dental office without your child having to go to an operating room in a hospital.  It provides your child with a tranquil, relaxed state that essentially relaxes your child enough for them to comfortably and safely have their dental treatment completed in one visit.  It may or may not cause a loss of consciousness and may cause amnesia, meaning that your child will probably not remember any of the procedure.  Amnesia is not a guarantee, but it is most likely.

Upon arrival at the office, your child will be re-evaluated to make sure there are no changes in their health history and make sure they have met all the safety requirements for starting the procedure. If we feel that there could be a potential health issue that could make things unsafe for your child or if the pre-appointment regulations are not followed correctly, we may have to cancel the case for your child’s own safety.  

Amy Koons, the CRNA, will evaluate how to best proceed with your child.  She will probably escort your child to our private treatment room, where she will administer a gas mixture of oxygen and nitrous oxide (aka “laughing gas”).  Once she feels that it safe for your child, the CRNA will give your child an injection of Ketamine. This is usually given in the thigh area.  This helps to alleviate anxiety and make the IV sedation and dental treatment faster and easier for them. It takes about 1-5 minutes for the ketamine injection to take effect. The ketamine will make them start to get sedated. Ketamine has the potential to cause amnesia effects where your child will probably not even remember any treatment done after this. The CRNA may or may not have you accompany them to the private dental treatment room. If you do accompany them back to the private the room, the CRNA will have you return to the designated waiting room when she decides.  If you do not accompany your child back, you will wait in the designated waiting room during this time until your child’s procedure is complete.  

Again, the combination of the ketamine and the laughing gas makes most children relaxed and comfortable enough to handle starting the IV.  Usually, a small dose of a numbing agent (injectable Lidocaine) is given with an injection at the site of the IV.  This is usually in your child’s arm vein but could be in the foot if needed.  Most children don’t even flinch, but they may notice a little discomfort.  Very few cry.  Please DO NOT tellyour child this is going to happen and let us word all treatment in a kid-friendly manner. 

Once the IV access is gained, your child will receive the sedative medicine through the IV as needed to complete the dental treatment.  The nitrous oxide will be stopped at this time, and your child will be given 100% oxygen for the remainder of the dental procedure.  The IV medicine typically used will be propofol.  It is very quick-acting and short-lasting, making it very desirable for outpatient procedures. It can only be used by qualified licensed anesthesia providers, as they are extensively trained in its use.  For your child’s safety, your child will be monitored thoroughly for the entire procedure by Amy Koons, CRNA.  Your child’s heart rate, rhythm, and blood pressure will be monitored with an EKG monitor.  To ensure your child has the proper oxygen levels, they will also be monitored with a pulse oximeter.  As an added indicator of quality breathing, the carbon dioxide exhaled by your child will also be monitored with a capnograph.  The monitoring procedures are the very same ones used by all anesthesia providers during all procedures that require this level of anesthesia.  Again, every measure it taken to ensure the safety of your child.

Your child will appear to be asleep but will not be completely put to sleep like they do at the hospital.  They will still be breathing on their own. There will be NO respirators or breathing tubes placed down your child’s throat, unless needed in an emergency situation.  Of course, we do not anticipate this being needed at all.  

Once your child is safely and adequately sedated, Dr. Nathan or the associate dentist will begin the dental treatment. This will be done as all dental treatment typically is.  Your child’s mouth will still need to be “numbed” with an injection. Dr. Nathan or the associate dentist will still numb your child’s mouth so that they will be more comfortable after the sedation has worn off.  Because they are already sedated, your child will not know this is happening.  Even so, please DO NOT tell your child this is going to happen and let us word all treatment in a kid-friendly manner.  Because they are already adequately sedated, Dr. Nathan or the associate dentist can start the dental treatment immediately and does not have to wait any time for the area to become numb.  All dental treatment will be completed before your child’s sedation wears off, so they will not be moving or discomforted by any of the dental procedures. Once the dental treatment is completed, the IV meds will be discontinued as the IV meds typically start to wear off in 5-10 minutes.  Your child will still continue to receive the 100% oxygen until they start to “wake up,” are alert, and start to want to get up. 

Once all safety requirements have been met, we will either come get you or bring your child to you.  Again, once they have met all the safety requirements to leave the office, you can then leave with your child.  They may be able to walk out on their own but may still be groggy from the medicine, requiring you to carry them to the car.  We can help you do this and do have a wheelchair if needed.  Your child should not return to school that day. They can return to school and normal activities the following day. 

Post-op instructions for IV sedation appointments.

•  Your child’s breathing pattern should be normal, but please watch this.  If they have any problems breathing or anything else that appears life threatening, call 911 immediately. SAFETY FIRST!!
• We will be monitoring your child for 15-30 minutes (or longer if needed) after the procedure (while you are with them) to make sure they are recovering as normal.  We will not let your child leave until we feel it is 100% safe for them to go home. We want them to be able to open their eyes, recognize you the parents, and communicate verbally with us. We also want to make sure they are breathing normal and not having any other issues before they leave.
• Your child will disoriented and groggy when they wake up. They may be crying, wailing, moaning, laughing, or be mad.  They may have all these emotions within 2 minutes.  Every child is different when they come out of anesthesia. These actions are temporary and will subside.
• Sometimes children become more and more upset the longer we are here in the office.  Even though they may be upset, once we feel it is safe to go home, we will allow your child to go home.  Most children return to normal within 1-2 hours after leaving.  Some are still upset longer.  Again, every child is different and complete recovery times can differ.
• Going to the car and going home. They will not be able to walk.  You will have to carry them downstairs to the car.  We do have a wheel chair if needed.  Once you get home, they may think they can walk.  They will not.  You will either have to carry them inside or walk them VERY SLOWLY inside the house.  You need to go straight home for them to return to their comfortable surroundings and to be able to monitor them accordingly.
• After any in-office IV sedation, it is best for your child to go home and rest. The initial sedative injection of ketamine usually wears off in 1- 2 hours but could stay in their system for about 6-8 hours. The IV meds may stay in their up to 24 hours, but usually is out of their system in 6-8 hours.  Please closely monitor their activity for the remainder of the day.  No physical activity until the following day.  They will not be able to go to school the day of the procedure but can return to school and all normal activities the following day.
• Eyes.  Their eyes may look glazed over or appear to be rolling back. They may say they cannot see well or see at all. This is temporary and should return back to normal in 30 minutes or so.
• Coughing/gagging.  They may be coughing or gagging some. This is because their throat is dry, and their mouth is numb.  This is normal. Drinking liquids will help alleviate this.  
• Bodily movements. They will probably be stretching their arms and legs out and be hard to hold in your lap.  You will need to support their head, as they may flail around.  This is normal and just a side effect of the medicine.  This usually happens within the first 5-15 minutes after the procedure is completed.
• Tongue.  If their tongue is numb, they may be sticking their tongue out rubbing it on their teeth. You may notice their tongue being red from any bleeding they may have in their mouth.  Keep in mind that they may drooling some from being numb. One drop of blood makes all the saliva look like blood, making it look like more blood than it actually is.  Their tongue will turn from red to black as the blood dries. This is normal and will just go away with drinking liquids. Because they typically rub their tongue on their teeth, they may say that their tongue is sore for a day or two after the procedure.  This would be normal.
• Bleeding.  Again, some bleeding in normal.  DO NOT PLACE GAUZE OR ANYTHING ELSE IN THEIR MOUTH WHEN THEY ARE SEDATED.  This could create a choking hazard.  Just let them drool and clean it up as needed. Any area in their mouth that is bleeding will not scab over, as you do not have a layer of skin in your mouth, and it always stays wet.  The area will look red for a day or two and then turn gray or white in color as it heals.  This is not an infection.  This is normal healing in the mouth.
•  Trembling. Their body or lips may tremble some.  This is another side effect of the medicine.  This is not a seizure and does not mean they are cold.  This usually happens right after the procedure is completed.
• There will be gauze and medical tape as a bandaid at the site of the IV. You may remove this at any time.  You may re-apply a bandaid as needed.
• Riding home.  It would be best if two adults could come to help.  One to drive the car, and one to ride in the back seat with your child to make sure they are ok, especially if you have a long ride home.  Make sure your child is safely secured in a car seat or seat belt on the ride home, as they may be “wobbly” or sleepy. It would be best if they can ride home with their head titled back or to the side and not with their head slumped forward.  Slumping forward can close their airway leaving them susceptible to having breathing problems.  Same for when they are sleeping at home.  Try to have them sleep on their stomach or side and not face down in the pillow.
• Sleeping.  Is it fine for your child to take a nap but be sure to monitor them frequently to make sure they are ok and breathing as normal.  They may drool in their sleep, creating a pool of blood on the area they are sleeping.  Remember, this is actually just a little blood and a lot drool, but the one drop of blood makes it all look like blood. You may want to put a towel down wherever they are sleeping.
• Eating and drinking.  Wait one full hour after treatment is completed before giving your child anything to eat, as their mouth will be numb during that hour.  We don’t want them to bite their lip, cheek, or tongue.  Please watch this, as some children will chew on their mouth anyway, and some kids are definitely numb more than one hour.  Softer foods would be best, but they are ok to eat whatever they feel like eating. Call us if you any problems. It is okay to give them something to drink, but they may drool.  Make sure they are alert enough to properly chew and swallow before giving them something to eat or drink. Drinking out of a straw is perfectly fine. Have your child drink plenty of liquids for the next 4-6 hours. You may want to avoid a lot of milk, as this could make them nauseous.
• Fever.  If you notice your child is running fever after treatment, Children’s Tylenol or Ibuprofen and plenty of liquids with help alleviate it.  The child’s temperature may be elevated to 101°F/38°C for the first 24 hours after treatment.
• Vomiting. Sometimes patients become nauseous or vomit due to not having any food or drink in their system. Some vomiting is normal. If they do happen to vomit and it persists beyond 4 hours, please call us.
• Pain or discomfort.  Unless otherwise directed by the dentist or CRNA, you may give Children’s Motrin, Advil, Tylenol, and Aleve. 
• Medications – talk to our child’s doctor at their hospital assessment appointment if you child takes medication for ADHA, Seizures, or Heart Conditions. DO NOT give your child any other medicines, before or after treatment, without checking with this doctor, the dentist, or the CRNA.  
• If the site where the IV was started is still irritated 24 hours after the procedure, you may place a heating pad or warm rag on the area to help decrease the irritation. You should try to place the heating pad on the area for about 5 minutes at a time.  You can do this up to 4 times per day.  A good rule of thumb is to do this once in the morning, once at noon, once in the afternoon, and once in the evening.  The irritation should subside in 1-2 days.
• If you have any concerns, please feel free to give us a call at any time. Dr. Nathan is on call all the time. We will be calling the same evening to check on your child.

Please call the office at 504-455-2213 if you have any problems at all.  Follow the prompts to leave an emergency message if no one answers or after hours.

• Always be positive.
• Be careful not to let your anxiety show – This has the most negative influence on the child’s behavior.  Be strong for your child.
• Avoid using words like “pain, hurt, needle, shot, drill”. For example, if you tell your child “This will not hurt”, they will focus on “hurt”.
• Please be sure to always use “kid-friendly” words.  We will be doing this as well.
• When preparing your child, DO NOT go into excessive detail about the procedure because you may show anxiety or say things that may trigger anxiety. It is best to let the dentist and assistants explain the details. We are all highly trained in this area.
• It is fine to offer a reward for good behavior but be careful not to offer bribes.
• Sometimes, children will cry when they are afraid or want to escape a situation. Some situations cannot be avoided. It is best to be reassuring and encouraging by saying things like “Good job” or “Be brave”. Crying is not bad and sometimes cannot be avoided. Remember – Be POSITIVE.
• Some children are better behaved when the parent waits in the waiting area. When the parent is present, these children will be disruptive in an attempt to have the parent remove them. Most of these children cooperate and are not disruptive when the child can deal directly with the dentist and/or assistant. In most cases, we like to try with the parent present first, but may need you to leave the room in certain cases.  Dr. Nathan will discuss this with you, if he feels this would be best for your child.