conscious sedation for dental procedures

CONSCIOUS SEDATION FOR

DENTAL PROCEDURES

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 Analgesia

Stage II Delirium

Stage III Surgical anesthesia

4 planes of surgical anesthesia

Stages of General Anesthesia

Stage IV Medullar paralysis

Provider Responsibilities

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 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 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

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 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 85150

Diastolic BP 50100

Rate BPM50 110

SP O2 92100

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 2 Move 2 extremities 1 No control 0

Respiration

Breathe deep and cough 2 Dyspnea 1 No respirations 0

Circulation

BP +/- 20% pre-sedation level 2 BP +/- 21-50% pre-sedation level 1 BP +/- > 50% pre-sedation level

0

Consciousness

Fully alert 2 Arousable 1 No response 0

Color

Pink 2 Pale, Dusky, Blotchy 1 Cardboard 0

METHODS

Sedo –analgesia Midazolam Fentanyl

Ultra light anesthesia Diprivan Ketamine

R.A Nitrous oxide

Valium (Diazepam)

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 4 times more potent than Valium

Produces sleepiness and relief of apprehension

Onset of action 3-5 minutes Half-life

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)

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 100 times more potent than Morphine

Pain attenuation and some sedation Onset of action around 1 minute Half-life

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)

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 Heart rate increases Salivary secretions decrease

Dose 0.1-0.2 mg Onset of action within 1 minute

METHODS

Sedo –analgesia Midazolam Fentanyl

Ultra light anesthesia 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

Syncope Hypoglycemia Hypotension Hypertension Bronchospasm

Laryngospasm Apnea Myocardial

infarction Stroke

Medical Emergency

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

Flumazenil (Romazicon) Naloxone (Narcan) Esmolol (Brevibloc) Ephedrine Epinephrine Atropine Dextrose 50% Lignocaine

Flumazenil (Romazicon)

Benzodiazepine antagonist Versed reversal agent

Initial dose – 0.2mg 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 Fentanyl reversal agent

Initial dose – 0.4mg 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