Download Intravenous Sedation

CONSCIOUS SEDATION
FOR
DENTAL PROCEDURES
by:
Dr. Adel Makhdoom
Anesthesia Consultant
Level of Sedation
• Awake
•
Conscious sedation ( sedoanalgesia)
•
Deep sedation
• General anesthesia
Conscious Sedation

A minimally depressed level of
consciousness which allows the patient to
independently and continuously maintain a
patent airway and respond appropriately
to verbal commands


Anxiolysis
Moderate Sedation
Consciousness
•
Protective reflexes
•
Patent air way
• Verbal contact
Deep Sedation

A controlled state of depressed
consciousness accompanied by a partial
loss of


protective reflexes and
the ability to respond appropriately to verbal
commands
C.N.S.Depressants
•Narcotics
•Tranquilizers
•Sedatives
•Hypnotics
•Induction agents
•Anticonvulsants
General Anesthesia

The elimination of all sensation
accompanied by the loss of consciousness
Stages of General Anesthesia

Stage I


Stage II


Analgesia
Delirium
Stage III

Surgical anesthesia

4 planes of surgical anesthesia
Stages of General Anesthesia

Stage IV

Medullar paralysis
Provider Responsibilities



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Pre-Procedure preparation
Pre-Procedure Patient Assessment
Intraoperative Responsibilities
Post-operative Responsibilities
Provider Responsibilities

Pre-Procedure preparation

Equipment
Instruments
 Venipuncture
 Monitors
 Emergency Supplies




“Crash Cart”
Cardiac Monitor
Medications
Diphenhydramine





Antihistamine that works at H-1
receptors.
Used for mild sedation & its
antihistamine properties.
May cause paradoxical
excitement.
May produce hypotension,
tachycardia, and urinary
retention.
Use with caution in infants and
young children.
Provider Responsibilities

Pre-Procedure Patient Assessment



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Vital Signs
Allergies
Contacts/Dentures
NPO status
Air way
Changes in medical history



URI
Hospitalizations
Sick family members
Airway Assessment

This picture
represents a
Mallampati Class One
airway. The entire
uvula and tonsillar
pillars are seen. This
individual should be
easy to mask
ventilate or to
intubate with a
laryngoscope and
endotracheal tube.
Airway Assessment

This picture
represents a
Mallampati Class
Three airway. None
of the uvula or
tonsillar pillars are
seen. This individual
may hard to mask
ventilate, and quite
difficult to intubate.
Airway Assessment

This image is
representative of an
extremely short
thyromental distance,
indicating tremendous
difficulty in tracheal
intubation, and
possible difficulty
establishing a
satisfactory mask
seal.
Special Considerations

Pediatric patients


Not “little adults”
Geriatric patients

Unique subclass of patients with physiological
changes complicating treatment
“Show Stoppers”


Food or fluid intake 6 hours prior to surgery
Clear fluid intake within 2 hours of surgery



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Can read newspaper print when looking through
liquid
Recent alcohol ingestion
Recreational drug use
Pregnancy
Thyroid Dysfunction
“Show Stoppers”





Recent asthma attack or respiratory failure
Treatment with MAO inhibitors
Tricyclic Antidepressants
Adrenal Dysfunction
Renal Dysfunction
Provider Responsibilities

Pre-Procedure Patient Assessment



Informed Consent
Escort Present
Establishes patient’s mental status
Under the influence of alcohol or drugs
 Oriented to person, place, time


Documentation
A.S.A physical status
classification



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
Class I A normal, healthy patient.
Class II A patient with mild systemic disease.
Class III A patient with severe systemic disease.
Class IV A patient with disease that is a constant
threat to his life.
Class V A moribund patient who is not expected
to survive without operation.
Provider Responsibilities

Intraoperative Responsibilities

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Informed consent signed prior to sedation
Name, dose, route and time of all medications
documented
Procedure begin and end times
Prior adverse reactions
Pre-medication time and effect
Provider Responsibilities

Intr-aoperative Responsibilities

Vital Signs
BP
 Heart Rate
 Respiratory Rate
 Oxygen Saturation
 Level of Consciousness

Provider Responsibilities

Post-operative Responsibilities

Vital Signs at least every 5 minutes
BP
 Heart Rate
 Respiratory Rate
 Oxygen Saturation
 Level of Consciousness


Sedated patients must be continuously
monitored until discharged
FACILITIES
The location should be of adequate size equipped to deal with
a cardiopulmonary emergency. This must include:
Tilted operating table, trolley or chair.
Adequate suction and room lighting.
A supply of oxygen and suitable devices.
FACILITIES (2)
Adequate equipments for artificial ventilation and airway management
- Appropriate drugs for cardiopulmonary resuscitation.
- Intravenous equipment.
- Pulse oxymeter.
- Defibrillator.
FACILITIES (3)
Emergency drugs should include at least the following:
•Adrenaline, atropine
•Dextrose 50%
•Lignocaine
•Naloxone, Flumazenil
MONITORING
Pulse oxymeter
B
Blood pressure
ECG
Capnometry
.
.
The following values are
indicative of the “normal”
adult patient. Pediatric and
Geriatric patients have
different values and unique
characteristics for which the
anesthesiologist/surgeon must
be aware
Blood Pressure

Specifically mean arterial pressure (MAP)

MAP
Systolic BP – Diastolic BP/3 + Diastolic BP
 Also written as Diastolic BP + 1/3 Pulse Pressure
 Normal 80-100
 Body loses auto regulatory capacity at a MAP less
than 50 or greater than 150

Heart Rate

Normal range 60-90
Respiratory Rate

Normal range 10-16 per minute
Oxygen Saturation

Must be greater than 90%

Supplemental oxygen via nasal canula

Initially 2-3 liters/minute
OXYGENATION
Degrees of hypoxemia occur frequently during intravenous
sedation without oxygen supplementation.
Oxygen administration
Pulse oxymetry
Recommended Alarm Limits
Low
High
Systolic BP
85
150
Diastolic BP
50
100
Rate BPM
50
110
SP O2
92
100
Level of Consciousness


Must be able to respond to verbal stimuli
by the surgeon in the clinic
May be greatly sedated or unable to
arouse by verbal stimuli in the operating
room
Provider Responsibilities

Post-operative Responsibilities


ALDRETE Post-Operative Scoring System
A cumulative score of 8 or above is necessary
for discontinuation of monitoring


We generally use a goal of 10 as necessary for
dismissal from clinic
Sum of standardized measurements of movement,
respiration, circulation, color and level of
consciousness
Movement



Move all 4 extremities
Move 2 extremities
No control
2
1
0
Respiration

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Breathe deep and cough
Dyspnea
No respirations
2
1
0
Circulation
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BP +/- 20% pre-sedation level
BP +/- 21-50% pre-sedation level
BP +/- > 50% pre-sedation level
2
1
0
Consciousness

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
Fully alert
Arousable
No response
2
1
0
Color
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Pink
Pale, Dusky, Blotchy
Cardboard
2
1
0
METHODS

Sedo –analgesia
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Ultra light anesthesia

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Midazolam
Fentanyl
Diprivan
Ketamine
R.A

Nitrous oxide
Valium (Diazepam)

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Benzodiazepine
Produces sleepiness and relief of apprehension
Onset of action 1-5 minutes
Half-life



30 hours
Active metabolites
Average sedative dose

10-12 mg
Midazolam (Dormicom)

Short acting benzodiazepine




Produces sleepiness and relief of apprehension
Onset of action 3-5 minutes
Half-life


4 times more potent than Valium
1.2-12.3 hours
Average sedative dose

2.5-7.5 mg
Buccal Midazolam

Concentrated formulation – 10mg/ml

Produced by Special Products

Formulated for use in Epileptic Patients
Demerol (Pethidine)


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
Narcotic
Pain attenuation and some sedation
Onset of action
 3-5 minutes
Half-life
 30-45 minutes
Average dose
 20-50 mg
Fentanyl (Sublimaze)

Narcotic/Opioid agonist



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Pain attenuation and some sedation
Onset of action around 1 minute
Half-life


100 times more potent than Morphine
30-60 minutes
Average dose

0.05 – 0.06 mg
The Key to Sedation

Local Anesthesia

If a poor local
anesthetic block has
been given, the
patient will continue to
feel pain throughout
the procedure
Additional Medications

Likely to be seen in scenarios where
deeper levels of sedation are being
performed


Propofol (Diprivan)
Robinul (Glycopyrrolate)
Propofol (Diprivan)



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Intravenous anesthetic/sedative hypnotic
Sedative, anesthetic and some antiemetic
properties
Onset of action within 30 seconds
Half-life


2-4 minutes
Average sedative dose

Varies
Robinul (Glycopyrrolate)

Anticholinergic



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Heart rate increases
Salivary secretions decrease
Dose 0.1-0.2 mg
Onset of action within 1 minute
METHODS

Sedo –analgesia



Ultra light anesthesia



Midazolam
Fentanyl
Diprivan
Ketamine
R.A

Nitrous oxide
Nitrous oxide
Minimum oxygen flow of 2.5 litres/minute.
Maximum flow of 10 litres/minute of nitrous oxide.
Minimum of 30% oxygen.
Ability for 100% oxygen.
Nitrous oxide
Ability to cut off nitrous oxide, and opens the system to allow
the patient to breathe room air.
Non-return valve to prevent re-breathing.
Reservoir bag.
Ability of scavenging of expired gases .
Low gas flow alarm.
Risks of chronic exposure to nitrous oxide .
Nitrous oxide
6 - 25%---------------------Moderate analgesia.
26 - 45%---------------------Dissociative analgesia.
46 - 65%---------------------Near complete amnesia.
66 - 80%---------------------Light anesthesia.
Medical Emergency

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Syncope
Hypoglycemia
Hypotension
Hypertension
Bronchospasm

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Laryngospasm
Apnea
Myocardial infarction
Stroke
Medical Emergency

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Know when and how to activate a “Code Blue”
Location of Crash Cart
 Medications
 Monitors
Location of emergency medications
BLS
Medical Emergency


Know how to prevent, recognize, and treat
syncope (fainting)
 Supplemental O2
 Elevation of lower extremities
 Trendelenburg
Be prepared to assist in airway management
Emergency Drugs


These are included
for reference only
Dentists should not
be administering
medications to
patients without
advanced training in
ACLS
Emergency Drugs

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Flumazenil (Romazicon)
Naloxone (Narcan)
Esmolol (Brevibloc)
Ephedrine
Epinephrine
Atropine
Dextrose 50%
Lignocaine
Flumazenil (Romazicon)

Benzodiazepine antagonist


Initial dose – 0.2mg



Versed reversal agent
May repeat at 1 minute intervals to dose of 1mg
Onset of action within 1-2 minutes
Must monitor for re-sedation

May be repeated at 20 minute intervals as needed
Naloxone (Narcan)

Narcotic antagonist


Initial dose – 0.4mg


Fentanyl reversal agent
May repeat every 2-3 minutes at doses of
0.4-2mg
Monitor for re-sedation
Esmolol (Brevibloc)



Antihypertensive
Beta blocker
Initial dose 0.25 –1.0 mg/kg over 30
seconds

Short half-life of approximately 10 minutes
Ephedrine




Used for hypotension
Sympathomimetic
Initial dose 5-10mg
Action may not be seen for several
minutes
Atropine

Significant bradycardia or asystole



Slow heart beat or NO heartbeat
Anticholinergic
Initial dose 0.25 – 1.0 mg


May repeat every 3-5 minutes
Maximum total dose .03 mg/kg
Epinephrine


True emergency medication
Administration should be preceded by
activation of the emergency response
system
Questions