Download Sedation for Dental Procedures

Sedation for Dental
Procedures
Dr Walid Zuabi
FCA RCSI
Consultant Anesthetist JUH
Sedation
• Definition:
A state of controlled depression of
consciousness that allows patients to
tolerate unpleasant procedures while
maintaining adequate cardiorespiratory function and the ability to
respond purposefully to verbal
command and/or tactile stimulation.
Stages of Sedation
Stages of Sedation
Aim of Sedation
• Achieving anxiolysis and patient
cooperation
• Drugs and techniques used should render
unintended loss of consciousness unlikely
- Local anesthesia  relief of Pain
- Sedation relief of fear and anxiety
- General anaesthesia  Relief of both
pain and anxiety
Which patient groups ?
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Dental Anxiety & Phobia.
Prolonged traumatic procedures.
Medical conditions aggrevated by stress.
Patient cooperation.
Special needs.
Which patient groups ?
• Children and young adults
• Anxious adults
Patient selection
• Only ASA I and ASA II groups should
undergo dental sedation in a general dental
practice (clinic).
Risk classification
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ASA I : A normal Healthy patient
0.06-0.08%
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ASA II : A patient with mild systemic disease
0.27-0.40%
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ASA III: A patient with severe systemic disease
1.8 - 4.3%
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ASA IV: A patient with severe systemic disease
that is a constant threat to life
7.8 - 23%
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ASA V: Moribund patient who is not expected to
survive without the operation
9.4-51%
• ASA VI: A declared brain dead patient whose
organs are being removed for donor purposes
• “E”
For Emergency surgery
Consent
* Informed, Written Consent regarding the
sedation procedure for a course of dental
treatment.
DRUGS USED
1- Benzodiazepines
2- Neuroleptanalgesia
3- Nitrous Oxide
4- Sedative Anaesthetics ( I.V. Hypnotic drugs)
SOAPME
Benzodiazepines
– Most widely used.
– Wide safety Margin.
– IV & Oral formulations available.
Benzodiazepines
Functions
1- Anxiolytic
2- Sedative (hypnosis)  sleep promotion
3- Amnesia/ RETROGRADE
4- Central muscle relaxant effect
5- Anticonvulsant
Benzodiazepines
• Diazepam
Oral:
2 mg q 8 hrs for anxiety
10-15 mg for premedication 2 hrs pre-op
(in Hospital)
• IV or IM.
painful on injection
 Diazemulus (lipid emulsion): painless on injection
5 mg/ml
Benzodiazepines
Diazepam
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(Continued)
Best anxiolytic
Poor amnesic
Minimal CV depression
Long Duration of action ( > 4 hrs)
Active metabolite
Benzodiazepines
Midazolam
• Indications:
- Conscious sedation
- Co-induction of GA
Doses:
- For pre-op sedation 0.07 – 0.08 mg/kg 1 hr
before procedure I.M injection
- Individualized dose I.V
Benzodiazepines
Midazolam
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Best amnesic , good hypnotic
Some CV depression
Readily produces general anesthesia
Duration < 2 Hrs
Benzodiazepines
Temazepam
• Only Oral.
• Doses :
- Insomnia : 10 – 30 mg
- Premedication: 10 – 20 mg 2 Hrs Preop
• Good Hypnotic
• Short duration
• May cause dysphoric reactions in young adults
Benzodiazepines
• Antidote: Flumazenil (Anexate)
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A specific antagonist
I.V
Essential requirement if Benzodiazepines are used.
0.2 mg IV every 15 seconds
Rapid recovery
Duration: 15 min
Re-sedation if long acting BZD is used
Can precipitate withdrawal reaction in habituated
patients.
Neuroleptanalgesia
• Major tranquilizers: chlorpromazine, droperidol
&
• Opiates: Fentanyl, morphine & Codeine
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• Many side effects 
- Behavioral syndromes:
- inhibition of purposeful movement
- inhibition of learned behavior
- catalepsy: a condition characterized by rigidity of extremities
and decreased sensitivity to pain
- Alpha adrenergic blockade
- Hypothermia
- Extra-pyramidal effects
- Anti-cholinergic effects
Neuroleptanalgesia
• Droperidol:
- Dose: 5 mg IV
- produce marked catalepsis
- Inner anxiety
- Duration 2 hrs
Fentanyl:
- Max. dose 1mcg/kg
- Potent Narcotic analgesic
- potent respiratory depressant
- Duration of action 35 min
cont.
Nitrous Oxide N2O
• LAFFING GAS!! LOL!!
Nitrous Oxide N2O
• LAFFING GAS!! LOL!!
Just Say N O!
2
Nitrous Oxide N2O
• LAFFING GAS!! LOL!!
Nitrous Oxide N2O
• LAFFING GAS!! LOL!!
Laughing Gas
Nitrous Oxide N2O
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Inorganic gas/ N2O
A strong analgesic
High safety margin
Can be used in concentrations up to 70%
Needs special administration machine
Needs a scavenging system
Use nasal masks with two-way valve outlets
Sedative Anaesthetics
- Propofol:
- Ultra-short acting
- Rapid clear headed recovery
- I.V infusion through a syringe pump
- titrate dose to desired response
- can achieve very well controlled sedation
- Very easy to render patient unconscious!!
- Should only be given by trained personnel in skills of:
- Tracheal intubation
- Artificial ventilation
- Cardiovascular resuscitation
Risks of Sedation
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Depression of Airway Reflexes
Inter-individual variability
Interactions with other medications
Allergic responses
Cardiovascular decompensation
Disinhibition reaction
Be prepared !!
• Patient check up:
- A concise medical history and relevant examination
and investigation
- General practitioner
• Assessment for potential airway problems
• Informed Consent
• NPO
Do you need an anaesthetist ?
Do you need an anaesthetist
present ?
Do you need an anaesthetist ?
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Possible airway problems
Very young / very old
Concurrent medical problem
Deep sedation ?
Monitoring
• Pulse Oximeter
• BP
• ECG
• Defibrillator
Emergency drugs that should be
available (in resuscitation trolley)
- Adrenaline
- Atropine
- Flumazenil
- Lignocaine
- Naloxone
- IVF
Recovery and Discharge
- Allow patient to recover in a quiet environment
- Patient must be supervised until fully recovered
- PACU should be equipped with same standards
of the procedure room
- Discharge after review by qualified practitioner
- Written instructions regarding home care
- Avoid alcohol, driving, machinery, signing documents
in case of a adults.
In Europe
• England, Ireland & Switzerland were the only two
countries in Europe where dental procedures under
deep sedation or G/A where carried out outside
hospitals i.e. in dental clinics.
• Training programs in conscious sedation for
dentists are provided in public sector and in certain
universities as a prerequisite for licensing .
Risk Management
• Using only familiar drugs
• Only to correctly indicated patients
• Comprehensive preoperative assessment
• continuous monitoring
• Appropriate emergency drugs and equipment
• Full documentation
• Well trained support personnel
• Treating high risk patients in a well equipped setting for their care
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