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Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies lanoxin 0.25mg online arrhythmia nclex. Evaluation of penicillin hypersensitivity: value of clinical history and skin testing with penicilloyl-polylysine and penicillin G: a cooperative prospective study of the penicillin study group of the American Academy of Allergy quality 0.25mg lanoxin blood pressure ranges for infants. Results of the National Institute of Allergy and Infectious Disease Collaborative Clinical Trial to test the predictive value of skin testing with major and minor penicillin derivatives in hospitalized adults discount lanoxin 0.25mg fast delivery arteriosclerosis vs atherosclerosis. Risk of administering cephalosporin antibiotics to patients with histories of penicillin allergy cheap 0.25mg lanoxin with mastercard blood pressure medication and zoloft. Cross-reactivity between penicillins and cephalosporins: clinical and immunological studies. Safety of cephalosporin administration to patients with histories of penicillin allergy. Lack of allergic cross-reactivity to cephalosporins among patients allergic to penicillins. The econcomic burden of antibiotic treatment of penicillin-allergic patients in internal medicine wards of a general teriary care hospital. Incidence of carbapenem-associated allergic-type reactions among patients with versus patients without reported penicillin allergy. Is it safe to use carbapenems in patients with a history of allergy to penicillin? Tolerability of meropenem in patients with IgE- mediated hypersensitivity to penicillins. Safety profile of meropenem: an updated review of over 6,000 patients treated with meropenem. Safe Use of meropenem in a patient with a possible nonimmediate allergy to imipenem. Safety of meropenem in patients reporting penicillin allergy: lack of allergic cross reactions. Brown Infectious Disease Division, Baystate Medical Center, Tufts University School of Medicine, Springfield, Massachusetts, U. Life-threatening reactions include arrhythmias, hepatotoxicity, acute renal failure, and antiretroviral therapy– induced lactic acidosis. During the latter half of the 20th century 6% to 7% of hospitalized patients experienced a serious adverse drug reaction (2). Approximately 5% of serious inpatient reactions were fatal, making hospital-related adverse drug reactions responsible for approximately 100,000 deaths in the United States annually. Therefore, attributing a particular adverse reaction to a specific antibiotic can be extremely difficult, may involve several factors operating in unison, and can tax the minds of the brightest clinicians. Adverse reactions associated with drug use include allergies, toxicities, and side effects. Examples of IgE-mediated type 1 hypersensitivity reactions include early-onset urticaria, anaphylaxis, bronchospasm, and angioedema. Non-IgE-mediated reactions include hemolytic anemia, thrombocytopenia, acute interstitial nephritis, serum sickness, vasculitis, erythema multiforme, Stevens–Johnson syndrome, and toxic epidermal necrolysis. Toxicity is a consequence of administering a drug in quantities exceeding those capable of being physiologically “managed” by the host, and is generally due to either excessive dosing and/or impaired drug metabolism. Examples of toxicity caused by excessive dosing include penicillin-related neurotoxicity (e. Decreased drug metabolism or clearance may be due to impaired hepatic or renal function. For example, penicillin G neurotoxicity may be precipitated by aminoglycoside-induced renal failure. Side effects reflect the large number of adverse reactions that are neither immunologically mediated nor related to toxic levels of the drug. This review describes adverse reactions and important drug interactions involving antibiotics. It concentrates on those agents likely to be used in critical care and is not encyclopedic. This article only briefly discusses antiretroviral drugs and antibiotic dosing; it does not address issues specific to pregnant or pediatric patients. In the critical care setting, these reactions may be masked by underlying conditions or other therapies. While anaphylaxis can be precipitated by antigen–antibody complexes, it is usually IgE mediated. The binding of antibiotic epitopes to specific preformed IgE antibodies on the surface of mast cells results in the release of histamine and other mediators that lead to the aforementioned clinical presentations. Conversely, only 10% to 20% of patients who claim to have an allergy to penicillin are truly allergic as determined by skin testing (10). Fifty percent of patients with a positive skin test will have an immediate reaction when challenged with penicillins (11). Approximately 4% of patients with a history of penicillin allergy who test positive to penicillin will experience a reaction (only rarely anaphylaxis) when given a cephalosporin (12). First-generation cephalosporins and cefamandole share a side chain similar to the chain present in penicillin and amoxicillin, and there is an increased risk of allergic reactions to these cephalosporins in penicillin- allergic patients. Other second-generation and third-generation cephalosporins have differ- ent side chains than penicillin and amoxicillin; a recent meta-analysis found no increased risk of allergic reactions to these cephalosporins in penicillin-allergic patients when compared with patients without a penicillin allergy (13). While early studies concluded that there is an increased risk of reactions in penicillin-allergic patients given carbapenems, recent studies have demonstrated that administering meropenem and imipenem to these patients is safe (14–17). Aztreonam can be given safely to patients with a history of anaphylaxis to all b-lactams except ceftazidime (9). A cohort study of patients receiving oral erythromycin found a two-fold increased risk of sudden death in patients receiving this macrolide (19). Myocardial depression, hypotension, and sudden death have been reported with vancomycin use, generally in the setting of rapid administration in the perioperative period (20,21). Similarly, rapid administration of amphotericin B has been associated with ventricular fibrillation and asystole, especially in patients with renal dysfunction (22). Mechanisms include decreased glomerular filtration, acute tubular necrosis, interstitial nephritis, and crystallization of the drug within the tubules. With regard to antibiotics, the aminoglycosides Adverse Reactions to Antibiotics in Critical Care 545 and amphotericins are the prototypical classes associated with acute renal failure; the availability of drugs with similar spectrums of activity that are significantly less likely to cause acute renal failure is the major reason that use of these drugs has markedly declined in the last two decades. As with other antibiotic-associated adverse reactions, the likelihood of antimicrobial-induced nephrotoxicity is greater in patients with conditions or on medications that independently cause this complication. Depending upon the criteria used to define acute renal failure, aminoglycoside-induced nephrotoxicity occurs in 7% to >25% of patients who receive these drugs (24). It usually results from tubular epithelial cell damage and presents as acute tubular necrosis. When using a small change in serum creatinine as the criterion for renal dysfunction (22) one study found that gentamicin (26%) is more nephrotoxic than tobramycin (12%) and that nephrotoxicity usually becomes evident between 6 and 10 days after starting the aminoglycoside. Aminoglycoside-induced acute tubular necrosis is usually non-oliguric and completely reversible. However, occasional patients require temporary dialysis and a rare patient requires chronic dialysis. Factors that contribute to aminoglycoside-induced nephrotoxicity include dose, duration of treatment, use of other tubular toxins (26), and elevated trough aminoglycoside levels (25).

So far order lanoxin 0.25 mg with visa prehypertension occurs when, the 1000 Genomes Project has Universal Free E-Book Store 696 24 Future of Personalized Medicine generated 3 lanoxin 0.25mg cheap prehypertension causes. In 2009 cheap lanoxin 0.25 mg online heart attack hereditary, the project is expected to up that dramati- cally safe lanoxin 0.25mg blood pressure 5332, producing a petabyte of data. Beyond the direct implications for the 1000 Genomes Project, the effort has spurred researchers to pioneer and evaluate methods that benefit other research efforts as well. There a need, however, for developing shared data formats for different stages of the analysis. In the absence of standard formats or a clear framework for such analysis, efforts to decipher the genetic information would be delayed. Consequently, team members are working to develop draft formats to aid this analysis. A better understanding of the genetic causes of longevity could have a major impact on the Indian Government’s healthcare bud- get and drug companies’ marketing efforts. The use of Affymetrix technology will enable researchers to correlate genes with longevity, as well as neurodegenerative condi- tions, breast cancer, diabetes and other complex diseases that affect the Parsi com- munity. The Parsi community was selected because of its longevity and its relatively genetically homogeneous population. This project takes a systems biology approach that encompasses not only genotyping but also expression profiling and transcrip- tomics. The genotyping phase of the project, which began in 2007, consisted of 10,000 samples in the first year. By the middle of 2008, the team had performed expression profiling and transcript mapping experiments across a subset of the sam- ples.. Data confidentiality is being maintained as in accor- dance with the Indian Council of Medical Research guidelines. Translational Science and Personalized Medicine Translational science deals with transfer of technologies from preclinical research into clinical application. There is a need for a comprehensive research agenda to move human genome discoveries into health practice in a way that maxi- mizes health benefits and minimizes harm to individuals and populations. A frame- work has been presented for the continuum of multidisciplinary translation research that builds on previous characterization efforts in genomics and other areas in health care and prevention (Khoury et al. The continuum includes four phases of trans- lation research that revolve around the development of evidence-based guidelines: • Phase 1 translation (T1) research seeks to move a basic genome-based discovery into a candidate health application (e. Because the development of evidence-based guidelines is a moving target, the types of translation research can overlap and provide feedback loops to allow inte- gration of new knowledge. Although it is difficult to quantify genomics research is T1, no more than 3 % of published research focuses on T2 and beyond. With continued advances in genomic applications, however, the full continuum of translation research needs adequate support to realize the promise of genomics for human health. Eventually, researchers hope to determine whether participating in personal genomic testing spurs individuals to make beneficial lifestyle changes such as improving their diet and exercise regimes. The team plans to track participants’ lifestyle changes using self-reported health questionnaires. Participants will complete the questionnaires at baseline and again 3 and 6 months after receiving the personal genetic test, which is designed to assess each individuals’ genetic propensity for more than 20 health conditions, including diabetes, hearts disease, and some cancers. Those enrolled will also be asked to participate in surveys periodically over the next 20 years. The results will be compiled in a database hosted by the Scripps Genomic Medicine program. To maintain participants’ genetic privacy, researchers will de-identify both saliva samples and health assessment questionnaires, encrypt the data, and store it in a secure database. In addition, researchers plan to use genetic variations identified in the study to improve their understanding of the genetics underlying diseases and the application of this genetic information for preventing, diagnosing, and treating diseases. Affymetrix will perform the genome scans, while Navigenics (now acquired by Life Technologies) will interpret the results and offer guidance on steps individuals can take to try to decrease health risks based on their personal genetic information. Personalized Predictive Medicine There has been an increasing emphasis on preventive medicine during the past decade and now predictive medicine is gaining popularity as an approach to improve healthcare in the future. Predictive medicine involves prediction of risk of disease in an individual and its personalized management. It is sometimes referred to as preemptive approach as it involves treat- ment before the disease develops. By the time most diseases are diagnosed, some damage is already done and in some situations it is irreparable. Moreover, chances cure of diseases such cancer would be anticipated to improve with this approach. Advances in molecular diagnostics, proteomics, and metabolomics are facilitating the development of tests for predictive medicine. The concept of predictive medi- cine is extended further to predict response of the disease to a particular therapeutic. A significant reduction in disease-related mortality as well as a reduction in costs can be expected if prevention and screening are focused on individuals at risk. In the pharmaceutical industry, predictive modeling of disease can be used to test efficacy of drugs before developing them. The following definition proposed: ‘Connected Health encompasses terms such as wireless, digi- tal, electronic, mobile, and tele-health and refers to a conceptual model for health management where devices, services or interventions are designed around the patient’s needs, and health related data is shared, in such a way that the patient can receive care in the most proactive and efficient manner possible’ (Caulfield and Donnelly 2013 ). Technological advances have made determination of genetic predisposition to disease possible and have gained wide use in medicine of developing personalized medicine. There is growing inter- est in the application of these genetic tests in predicting risk for complex genetic diseases as direct-to-consumer tests are increasingly becoming available and afford- able. Evolution of Medicine as a Driver for Personalized Therapy Markets There are no revolutions in medicine but evolution. This process has already been set in motion by the advent of the genomic era and will continue. Pharmacogenetics is increasingly driven by industrial researchers, partly because of their ready access to clinical trial data on which phar- macogenetic research can be carried out. The future generation of physicians in training should be learning about personalized medicine at their formative stage and the current restrictions about the participation of the commercial sector in this effort needs to be relaxed. The industry can maintain its lead in the use of modern communication tools, such as the Internet, to allow patients to provide samples for future research yet retain control of them in the light of future developments. Both industry and aca- demic researchers have a common goal in that both want to bring innovative solu- tions into clinical practice to improve health care. Universal Free E-Book Store Opportunities and Challenges of Personalized Medicine 701 Presymptomatic treatment Integrated healthcare Personalized medicine 2010-2015 Automated systems Rational therapies Bioinformatics Genetic screening Evolving medicine 2005-2010 Pharmacoproteomics Pharmacogenomics Pharmacogenetics Medicine in 2000-2005 beginning of 21st Molecular diagnostics century Empirical treatments © Jain PharmaBiotech Fig. Currently there are some reservations about the value of genetic testing in prediction of disease as there are multiple factors involved. It is currently being debated if it is worthwhile to continue with the multi-million dollar genomewide studies or to decode the entire genomes of individual patients. Although genomewide association studies have worked better and faster than expected, they have not explained as much of the genetic component of many Universal Free E-Book Store 702 24 Future of Personalized Medicine diseases and conditions as was anticipated, and suggestion has been made to turn more sharply toward the study of rare variants (Goldstein et al. Thus schizo- phrenia would be caused by combinations of 1,000 rare genetic variants, not of 10 common genetic variants. One should be concerned about diseases for which testing shows that an individual’s risk is three times as great as average, but not for trivial increases in risk.

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Organ Manifestations At autopsy cheap 0.25 mg lanoxin overnight delivery blood pressure chart new zealand, organs with high blood flow 0.25mg lanoxin for sale blood pressure chart high systolic low diastolic, including lungs 0.25mg lanoxin overnight delivery arteria tapada sintomas, spleen lanoxin 0.25 mg without a prescription blood pressure drop, liver, bone marrow, kidneys, and adrenals, are frequently affected. Respiratory symptoms (cough, dyspnea, pleuritic chest pain) are present in 30% to 70% of patients. Commonly reported symptoms include abdominal pain (diffuse or localizing to the right upper quadrant), nausea, vomiting, and diarrhea. Liver function tests are frequently abnormal and typically suggest a cholestatic pattern. Frank jaundice, ascites, cholecystitis (31), and pancreatitis (32) are rare, but elevations of alkaline phosphatase and transaminases were reported in 83% and 42% of patients in one series (33). The most typical skin lesions, termed “tuberculosis cutis miliaris disseminata” or “tuberculosis cutis acuta generalisata”, are described as small papules or vesiculopapules (37). Rarely lichenoid, macular, purpuric lesions, indurated ulcerating plaques, and subcutaneous abscesses have been reported (35,37). Adrenal gland involvement has been found in as many as 42% of autopsy-based case series (38). Even in autopsy series, cardiovascular involvement, with the exception of pericarditis, is distinctly rare. The problem is to consider the diagnosis in time and to initiate diagnostic work up and therapeutic interventions without delay, as the host is generally not able to control M. A typically normocytic, normochromic anemia is seen in approximately 50% of the patients. Most patients have a normal white blood cell count, but leukopenia and leukocytosis 424 Albrecht occur in an approximately equal minority of patients. Pancytopenia due to bone marrow infiltration or a hemophagocytic syndrome has been described. Hyponatremia, the most common biochemical abnormality, often indicates inappropriate antidiuretic hormone secretion. Hypercalcemia and polyclonal hypergamma- globulinemia have been reported in several cases. Bronchoalveolar lavage tends to reveal absolute and relative lymphocytosis, but mostly due to conflicting results no other useful markers have been identified. Miliary Tuberculosis in Critical Care 425 the onset of clinical symptoms (24,33,45,46). The initial nodular interstitial spread occurs without significant alveolar involvement. In order to be large enough to be appreciated on a plain chest radiograph, however, some spread to the adjacent alveoli will have to have occurred (47). Furthermore, while many studies report extraordinary high rates of classic radiologic findings; this usually is a self-fulfilling prophecy as the radiologic findings were often used as an inclusion criterion as well. Asymmetrical nodular pattern, coalescing nodules, mottled appearance, snowstorm appear- ance, ground-glass appearance, and air-space consolidation have been described (3). Conversely, other conditions that typically present with larger nodules such as alveolar hemorrhage, lymphangitic cancers, or inhalational diseases can appear as early small nodules. Approximately 5% of patients have additional findings that may provide additional clues to the diagnosis. Subtle miliary lesions are best appreciated in slightly underpenetrated films, but in many cases visualization requires a high index of suspicion and review with an experienced chest radiologist. Numerous small (1–3 mm) nodules, distributed throughout both lungs, are easily visualized. A recent review, however, came to the conclusion that “in the published reports, no systematic pattern of diagnostic approach could be identified and invasive diagnostic sampling appeared to be arbitrary and individualized, especially in the pediatric series” (3). While it is indeed difficult to generate evidence-based recommendations for testing, recent studies have helped establish several important testing paradigms (24,33). However, the probability of a positive smear increased with the number of sites sampled. Thus, when present, samples of sputum, gastric aspirate, urine, pleural fluid, pericardial fluid, and ascites should all be rapidly examined for the presence of acid-fast bacilli. Fluorochrome dye–based stains may be more sensitive than conventional Ziehl–Nielsen staining (52). It should be noted that neither of these traditional stains allows for distinction between tuberculous and nontuberculous mycobacteria, but direct probes have been developed that allow for species detection in smear-positive samples (53). Cultures tend to be more sensitive, but the turnaround time of several weeks significantly diminishes their usefulness in the critical care setting. However, even if the results may not be available in time before treatment decisions have to be made, it is extremely important to procure tissue/fluids as positive cultures are prerequisite for later drug-susceptibility testing. All specimens should be inoculated into an automated radiometric detection system, preferably using lysis centrifugation techniques, which is both more rapid and more sensitive than standard techniques using solid medium for the isolation of M. These tests produce results within two to seven hours after sputum processing and are therefore of interest in critically ill patients. False-positive or false-negative results occur more frequently when technician proficiency is suboptimal. While sensitivity and specificity are somewhat depen- dent on pretest probability, all available tests perform better in smear-positive samples than in smear-negative patients. Molecular rapid tests have generally replaced adenosine deaminase and interferon- gamma-based tests that have mostly been evaluated in resource-limited settings with high pretest probabilities. In the two modern case series, granulomas were demonstrated in up to 100% of liver biopsies, 82% of bone marrow biopsies, and 72% of transbronchial biopsies (24,33). If biopsies were guided by clinical or laboratory abnormalities specific to Miliary Tuberculosis in Critical Care 427 the organ system being sampled, the yield was generally higher. Specific target amplification can be performed on fresh and even processed samples. Pulmonary function tests often show abnormalities, but no characteristic pattern have been identified that would increase the diagnostic yield of other studies. Differential Diagnosis The differential diagnosis of febrile illnesses with miliary chest X-Ray infiltrates is broad and includes infectious and noninfectious entities. Bacterial infections described in the literature include legionella infection, nocardiosis, pyogenic bacteria (Staphylococcus aureus, H. Viral infections (varicella, cytomegalovirus, influenza, measles) and parasitic infections (toxoplas- mosis, strongyloidiasis, schistosomiasis) can produce similar patterns. Neoplastic diseases, including lymphoma, lymphangitic spread of various cancers, or mesothelioma, are in the differential diagnosis as are other diseases including sarcoidosis, amyloidosis, hypersensitivity pneumonitis, alveolar hemorrhage, storage disorders, pneumo- conioses, and foreign-body-induced vasculitis related to injection drug use. Delay in the diagnosis or initiation of treatment contributes to the high mortality. Each regimen has an initial phase of two months followed by a choice of several options for the continuation phase of either four or seven months. The choice of treatment in the initial phase is empiric as susceptibility data are usually not available or only available at the end of the initial phase of treatment.

Detailed descriptions of management of a variety of medical problems appear in a comprehensive book by Scully and Cawson (1998) discount 0.25 mg lanoxin heart attack or pulled muscle. The decision as to whether a patient should be treated under general anaesthesia or local anaesthesia lanoxin 0.25mg with visa hypertension zinc, or local anaesthesia with sedation depends on a combination of factors cheap 0.25mg lanoxin with visa blood pressure 50 over 70, the most important of which are: (1) the age of the child; (2) the degree of surgical trauma involved; (3) the perceived anxiety and how the patient may (or has) responded to similar levels of surgical trauma; (4) the complexity of the operative procedure; (5) the medical status of the child generic lanoxin 0.25mg visa pulse pressure nhs. There are no hard and fast rules, and every procedure in every child must be assessed individually and the different elements considered in collaboration with the parent and, where appropriate, with the child. For example, the younger the child the greater the likelihood of a need for general anaesthesia. At the other end of the age range it is unlikely that a 15-year old will need general anaesthesia for simple orthodontic extractions, although this might be required for moderately complex surgery, such as exposing and bonding an impacted canine. The degree of trauma involved is also another factor; a single extraction is most likely to be carried out under local anaesthesia, removal of the four first permanent molars is most likely to be carried out under general anaesthesia. Anxiety perceived as excessive, especially after an attempt at treatment under local anaesthesia and sedation, would lead to simple treatment such as conservative dentistry being carried out under a general anaesthetic usually involving endotracheal intubation. Serious medical problems, for example, cystic fibrosis with the associated respiratory problems would justify using sedation instead of general anaesthesia even for more traumatic surgery, such as removal of impacted canines, but it would be appropriate to carry out this sedation in a hospital environment. The degree of intellectual and/or physical impairment in handicapped children would also be a factor to be considered. General anaesthesia carries with it a finite risk of serious morbidity such as psychological trauma and even death (3 to 4 per million). No child should be submitted to a general anaesthetic without consideration of this potentially devastating outcome. Intermediate between the minimally intrusive techniques of local anaesthesia and the major intrusion of general anaesthesia are the techniques of conscious sedation (Fig. Key Points • Each child should be assessed on their merits and an appropriate method of pain control used. The drugs and techniques used to provide conscious sedation for dental treatment should carry a margin of safety wide enough to render unintended loss of consciousness unlikely. The level of sedation must be such that the patient remains conscious, retains protective reflexes, and is able to understand and respond to verbal commands. The routes of administration of sedative drugs used in clinical paediatric dentistry are oral, inhalational, intravenous, and transmucosal (e. However, the transmucosal routes are little used in the United Kingdom and currently, intravenous sedation is considered unsuitable for the operator/sedationist when working on children. Key Point • The goal of conscious sedation is to use a pharmacological agent to augment behavioural management to decrease anxiety levels while maintaining a responsive patient. Although the techniques are designed to reduce this risk to a minimum it should always be borne in mind that every time a sedative is given to a patient there is a risk of an idiosyncratic reaction to the drug, which may result in hypoxia or unexpected loss of consciousness. The clinician must arrange the clinical session so that sedation, irrespective of complications, can proceed smoothly and safely. This includes the need for all patients who are having sedation to be accompanied. This can be any adult, who understands the implications and potential problems of caring for a child during the later stages of recovery. In addition, the clinical facilities need to include suitable resuscitation equipment coupled with the knowledge and skills to use them. Key Points • The main complications related to paediatric conscious sedation are: -hypoxia, -nausea, -vomiting, -inadvertent loss of consciousness (general anaesthesia/over sedation). For this reason emergency equipment and drugs should be within arms reach of the operator and ready for immediate use. Training of the dental team is a requirement, irrespective of whether conscious sedation is practised. It is essential that each member of the dental team knows exactly what is required of them in an emergency. This must be capable of reaching the floor as a patient may be removed from the dental chair to lie on the floor to enable resuscitation. A regular working supply of oxygen from an inhalation sedation unit is an alternative. Note: These items should form part of an armamentarium of any dentist when treating patients using local anaesthesia alone. Training of the dental surgeon and their staff in the use of drugs has the same requirements as for equipment. Adrenaline hydrochloride 1 mg/ml (1000 mg/ml), that is, 1 : 1000 on a 1 ml ampoule for subcutaneous or intramuscular injection. In addition to the above drugs suitable needles and syringes should be available to enable drugs to be drawn up and administered parenterally. Flumazenil (benzodiazepine anatagonist) for reversing unexpected over-sedation from orally, intravenously, or rectally administered benzodiazepine. A laryngoscope, endotracheal tubes, and forceps to manipulate the endotracheal tubes during intubation. It is the responsibility of the dentist to ensure the availability of the drugs required by the medical staff who may be called to deal with an emergency. Equally, it is the responsibility of the same medical staff to advise the dental surgeon of his or her precise requirements with regard to emergency drugs. These can be reviewed by reading the following: European Resuscitation Council (1992). As a general rule it is not wise to let children have medication at home as quiet supervision of the child within the surgery premises is prudent. A journey to the surgery under the increasing influence of a mood-altering drug is not the most propitious way of preparing distressed children for treatment. However, the facilities suitable for providing care apply equally to oral, inhalational, and intravenous sedation. During treatment there must be effective suction equipment and in the event of a power failure, a mechanically operated backup. Sedated patients often hallucinate or misinterpret words and actions and so, a chaperone to safeguard the operator- sedationist is also essential. Once treatment is complete the child should be able to sit (or lie) quietly until sufficiently recovered to be accompanied home. A further important strategy is to have a checklist so that the dental surgeon can be sure that all important elements of sedation have been properly considered. Postoperatively, suitable arrangements need to be in place for travel and to ensure that the child plays quietly at home. Key Points To carry out conscious sedation: • informed consent is mandatory; • preoperative and postoperative instructions should be given prior to the sedation visit; • patient assessment includes medical, dental, and anxiety history; • appropriate facilities, child-friendly environment and sedation trained staff are essential; • the operator-sedationist, irrespective of gender, must be chaperoned at all times; • the child must be accompanied by an adult escort; • a checklist is important to ensure all preparations are in place. For this reason, the facilities outlined above are necessary in the unlikely event of unexpected loss of consciousness. It is important that dental surgeons working with children have a very clear idea of the clinical status of sedated patients.