Alphaprodine in Twenty Years of Sedation Experience Dr

Alphaprodine in twenty years of sedation experience Dr. Creedon Robert L. Creedon, DBS

klphaprodine was first used for premedication least the preceding year. There were many that did of dental patients at the Cincinnati Children's not fit that category. Hospital Medical Center in 1966 following the We have always had a large population of older, discovery of an article published, tlrnt year in the profoundly retarded patients. We have been asso- Journal of the American Society of Dentistry for ciated for twenty years with the Hamilton County Children by Maurice C. Corbett. Prior to that time Diagnostic Center for Mental Retardation, now the a variety of medications had been used. Cincinnati Center for Developmental Disabilities. We My own personal experience with premedication also have a large population of cerebral palsy patients began over twenty years ago with a phenothiazine from the very young to the adult who many times called promazine hydrochloride (Sparine®). It was un- cannot find dental service in our community. forgettable in that we ended up resuscitating our pa- We quickly discovered that alphaprodine was the tient, who was an adult male, on the floor of the best agent we had tried for children between the ages operatory. Promazine was used often, however, and of 21/2 to 6 years. We have used the drug in younger that one case was our only major complication. children, but only rarely, for very short procedures Since that time we have employed a wide variety such as the extraction of anterior primary teeth or of drugs alone and in combination; and sometimes for trauma management in the emergency room. in large doses. I can recall an instance in which l.Scc Alphaprodine has been used in adolescent and young of Mepergan®, which is 75 mg of meperdine and 75 adults, but the objectives were somewhat different mg of promethazine in the 50 mg/cc concentration, as were the responses obtained. was used for a seventeen-year-old profoundly retarded We have always used alphaprodine via the buccal patient. The only effect produced was nausea and vestibular or retromolar pad injection. We would emesis; almost no sedation. Other drugs used over estimate that over the 20 years we have probably the years have been promethazine, hydroxazine, sedated approximately 5,500 to 6,000 patients, but chloral hydrate, and diazepam. Many types and com- it is impossible to say how many of those were given binations have been used since we have so many alphaprodine. Alphaprodine became a favorite agent physically handicapped and mentally retarded pa- of all who have worked with us. In fact, a local tients who are large, severely involved adolescents. pedodontist on our attending staff began using the Yet another combination used has been the "lytic" drug at the same time we did and has treated approx- or "cardiac" cocktail consisting of meperidine, pro- imately 1,500 to 2,000 patients, with about 400 cases methazine and a phenothiazine. It is a very effective in the year prior to its withdrawal from the market. combination as one might expect, but it also has We were able to document only 75 cases since we did many serious side effects. It is most often used for not keep a record of past patients from the general cardiac catheterization and occasionally will produce patient population who might have received respiratory depression of some magnitude, and even alphaprodine. arrest. In all of our patients treated by whatever means, In order to put our early use of premedication into we have had only one case of apnea. That occurred proper prospective, one needs to have an apprecia- in a three-year-old child one minute after the injection for the patient types and the situations that we tion of alphaprodine. The patient became apneic were working under in those days. Our facilities were following injection and was reversed immediately in satellite operations spread around the city of Cin- with an antagonist. With the antagonist and oxygen, cinnati. We were not able to bring patients to the the patient regained consciousness quickly and had Children's Hospital for general anesthesia unless no further problem. We have had many cases where they were patients of record of the hospital for at alphaprodine was ineffective. It is the best agent we

PEDIATRIC DENTISTRY: Volume 4, Special Issue 1 187 have used in all of these years, but it is still not siderations which still make alphaprodine the drug effective for ever.vone. of choice in our opinion. There were more treat- A Foldes, Zedick, et al. report in the American ment failures with fentanyl than we ever had with Journal of Medic~lSciences in 1957, studied the ef- alphaprodine. fects of narcotic a~algesics and narcotic antagonists The drug does not help with combative patients. on respiration. These investigators reported that the There are great individual variations of response. respiratory depression caused by meperidine and Because of the small concentration, large volumes alphaprodine cou]ld be prevented by either giving must be used which can be a problem with buccal levalorphan tar~Lrate ILorfan ®) or nalorphine vestibule injection. This injection tends to be more {Nalline®~prior to, or in combinationwith, the nar- toward an intravascular type than subcutaneous. cotic. Becauseof that discovery, we began to utilize Large doses given intravenously have been reported this method occasionally, until naloxone became to result in rigidity of the chest wall. Respiratory available. Naloxone works better than levalorphan depression is a knownside effect of fentanyl. tartrate or nalorphine. Weabandoned the routine The meperidine and chloral hydrate combination reversal techniques shortly thereafter, simply works well. The problemhere is that the patients are because we felt it was unnecessary. sedated for a long period of time and one has to deal with the problem of sending a sedated patient home with the parent. Whenthese patients are awakened, A1phaprodine became a favorite agent an important criteria for sending them home, we try of all who have worked with us. to make sure that they can ambulate and that they can hold their heads erect. Our choice of drugs is based solely on personal preference, observed patient behavior, utilization, Prior to 1973 we did not employnitrous oxide/oxy- and the need to avoid postoperative problems occur- gen to supplement our sedation techniques, because ring whenthe patient is no longer in our hands. The it was not available. Nowit is the only agent we use only prejudice we would profess would be against in combination with alphaprodine, with the possible promethazine whether it is used preoperatively or in exception of cases, in which we desire extending the combinationwith another drug. It is our feeling that clinical effects to about 1 to 1½hours. In these cases it is an unpredictable agent, particularly in children. promethazineis u:sed, in the amountsof 0.15 to 0.25 Our anesthesiology department has reported many cc of the 50 mgper cc concentration, injected into instances of hypotensive side effects and extra- the retromolar pad. Weprefer the administration of pyramidal experiences with promethazine. promethazine to repeating the dose of alphaprodine. The considerations for premedication are as Our criteria for the use of sedation is the same follows: today as it was 20 years ago. Our age range for 1. preoperative informed consent, alphaprodine use is 2V~to 6 years and we consider 2. patient must not have eaten for three or four its use with the combativechild in particular. Wealso hours prior to appointment, use alphaprodine in recalcitrant, frightened, 3. patient must be healthy without respiratory hysterical children in whomwe have tried voice con- ailments {such as colds}, trol and nitrous oxide to no avail. The drug is used 4. accurate weight of the patient must be in patients requiring extensive restorative treatment established, which is to be completedin one sitting. It is useful 5. baseline vital signs must be determined {though in patients requiring extractions, suturing of lacera- they are sometimesdifficult to obtain), tions, and restoration of anterior primary teeth, as 6. the parent must remain in the office for the dura- in nursing bottle caries. The dosage employed has tion of procedure and recovery. always been 1.1 mg per kg {0.5 mg/lb.). There are The intraoperative considerations are as follows: those occasions when, with a 2½ year-old, the dose 1. mild restraint, e.g., the Pedi-Wrap~ or Papoose would be reduced. Weinject the drug submucosally Board, into the retromolar pad area, the site of mandibular 2. a quiet treatment environment, block injection or !in the buccal vestibule of the max- 3. nitrous oxide induction, ilia. No combinationsare used. Nitrous oxide/oxygen 4. a fully stocked crash cart available with a team is used adjunctiwfly. trained in CPR, When alphaprodine was withdrawn from the 5. patient monitoring by carotid or temporal pulse, market, we began using fentanyl or a combination respiration (rate and depth) and blood pressure, of meperidine and chloral hydrate. Both of these regimens work, but they have many different con- ~Clark Associates, Worcester, MA.

188 ALPHAPRODINESEDATION EXPERIENCE: Creedon 6. makingsure that the restraints are not confining One excellent feature is that the monitor is capable the patient’s capability to breathe and that an air- of producing readings of meanarterial pressure even way remains absolutely patent at all times. at very low blood pressures. A trend recorder is also available for use with the monitor. This is a thermal printer whichrelies on soft- We also use alphaprodine in ware stored in the monitor. It must be connected via recalcitran t, frightened, hysterical an interface cable to the monitor in order to function. Weuse a precordial stethoscope along with the ctu’Idren in whom we have tried voice ® control and nitrous oxide~oxygen to no Dynamapmonitoring device. Wewould suggest the use of a Dynamap® or some automatically inflatable avai/. cuff and a spring loaded sphygmomanometer.Sys- tolic pressure can be read from a needle jump and you do not have to listen to it with a stethoscope. If you Post-treatment considerations are: are in a situation where a quick determination of the 1. not releasing the patient until he is able to hold cardiac status of your patient is needed, the systolic his head erect, verbalize and ambulate, pressure is the important consideration. 2. cautioning the parent to frequently observe the It is of course very nice to have all of these airway and color of the patient and keep he or she mechanicaldevices, but I’d like to stress that it is turned on one side, also very easy to come to rely too heavily on 3. cautioning the parent to give solid foods only mechanical equipment. The more you deal with them, whenthe patient asks to be fed. the more you tend to rely on them. Youneed to keep Accurate patient monitoring is essential to good reminding yourself that devices need to be checked premedication management. This is especially true and calibrated often. in the dental setting where the operator oftimes does By way of summary,I would like to say that in all the patient monitoring. The dental assistant can be of these years of experience, I still feel that Roche trained to monitor the sedated patient of course. has the best agent for us at this time. Generally, the Sometype of mechanical, automatic patient monitor- results with alphaprodine have been excellent. We ing system is preferable. have not had situations that we couldn’t handle. It One such device is the DynamapMonitor®. b The is myown personal opinion that those reported cases monitor gives a digital readout of systolic and of problems could have been avoided. Obviously, diastolic blood pressure, heart rate, and meanarterial some cases require general anesthesia and we will pressure. Determinations are made at automatic continue to utilize general anesthesia when nec- preset intervals, from one to five minutes apart, essary. Alphaprodineis me.rely another modality for utilizing an inflatable cuff controlled by the monitor. pediatric dentists. An automatic alarm system which is either visual or auditory is built into the instrument. The operator Dr. Creedon is professor and director, dental department, Children’s presets the limits for the alarm prior to the procedure. Hospital Medical Center, 240 Bethesda Avenue, Cincinnati, OH bCritikon Corp., Tampa, FL. 45229. Reprint requests should be sent to him.

PEDIATRIC DENTISTRY:Volume 4, Special Issue 1 189