sedation techniques

7/26/2019 Sedation Techniques

1/57

Kyle J. Kramer, DDS, MS

2/24/11

Sedation Protocols


2/57

Goals

! Rational for selecting sedation techniques! Enteral (oral)

!

Parenteral (IV)

! Dental procedures possible while utilizing sedation! Common concerns

!

Common sedation protocols! Enteral (oral)

! Parenteral (IV)


3/57

Goals

! Preoperative instructions for sedation patients

! NPO Guidelines

! Post-sedation protocol

! Discharge criteria

! Common postoperative instructions


4/57

Indications for Sedation

! Comfort and care

! Profound relaxation

!

Long procedures! Invasive procedures

! Behavioral Modification

!

Gagging! Uncooperative nature


5/57


! Anxiety! Situational anxiety

!

Dental phobia

! Medically Compromised Patients! Cardiovascular disease

! Pulmonary disease

!

Cerebrovascular disease! Seizure disorders

! Etc


6/57


! Goal: Adapt YOUR techniques to the patient

! Mix and match!

Extraction = IV sedation!

Implant = Oral + nitrous oxide

! Uncovery = Nitrous only


7/57

Selection Rationale

! Provider preference

! Comfort and familiarity

!

Appropriate licensure!

Adequate training

! Appropriate resources


8/57

Selection Rationale

! Patient selection

! ASA Classification!

How healthy is my patient?! Anticipated problems

! What are they and are you capable of managing the problems?

! Will they tolerate the sedation protocol I have selected?! Example: Conscious sedation on pediatric patients


9/57

Selection Rationale

! Surgical Plan

! How long is the procedure going to be?!

BE REALISTIC!! Does your surgical plan compromise your sedation plan?


10/57

Selection Rationale

! IDEAL: Ability to titrate sedation! Depth of stimulation

! Duration of surgery

! What is expected amount of postoperative pain! Immediate postop

! Usually easily controlled with LA in dentistry

!

Once back home! OTCs

! Rx


11/57

Dental Procedures

! Almost all dental procedures are safe to performconcurrently with minimal or moderate sedation

!

Minor modifications may be needed!

Rubber dam

! Isolite

! C-sponges

! Throat pack


12/57

Dental Procedures: General DentistryProcedures Concerns

! Evaluations

!

Radiographs! Routine treatment

! Drill & fill

! Crown & bridge

!

Implants! Extractions

! Placement

! Uncovering

! Irrigation

!

Loose restorative materials! Alloy

! Implant components

! Obstruction of airway

!

Radiograph holders! Impression trays


13/57

Dental Procedures:

Periodontal TherapyProcedures Concerns

! Nonsurgical

!

Prophy! DSRP

! Surgical procedures

! Open flap debridement

! Soft tissue grafts

! Irrigation

!

Intraoperative bleeding


14/57

Dental Procedures:

Endodontic TherapyProcedures Concerns

! RCT

!

Surgical/invasive therapy! Apicoectomy

! Irrigation

!

Intraoperative bleeding! Obstruction of airway

! Radiograph holders

! Microscope?


15/57

Dental Procedures:

Oral SurgeryProcedures Concerns

! Extractions

!

Invasive procedures! Biopsies

! Tissue grafts

! Incision & drainage

! Irrigation

!

Intraoperative bleeding! Obstruction of airway

! Loose teeth

! Radiograph holders

!

Microscope?


16/57

Key to Success!

! Think through the surgical plan ahead of time and takenecessary precautions


17/57

Oral Sedation Rationale:

Benzodiazepine

! Diazepam, Midazolam or Triazolam??

! Ideal for:

!

Anxious patients! Rest the night before the appointment

! Procedural sedation


18/57


Diazepam, Midazolam or Triazolam??

! All provide relatively similar levels of sedation at equipotentdoses

!

Anxiolysis! Amnesia possible

! Relatively safe

! Minimal cardiovascular or respiratory depression when usedalone


19/57



! Worried about active metabolites (think renal dysfunction!)! Diazepam?

! Maybe not

!

Worried about prolonged recovery/resedation?! Diazepam?

! Maybe not

! Duration of surgical procedure! Diazepam > midazolam = triazolam

!

Diazepam produces slightly different type of sedation

! Patient age! Preoperative midazolam for children


20/57

Oral Sedation Rationale


! Can combine with nitrous oxide to achieve moderatesedation

!

Requires more monitoring/vigilance!

Monitor for oversedation/hypopnea

! Recommend pulse oximeter

! Obtain baseline, then titrate in N2O!

Able to titrate to level of stimulation

!

Rapid recovery?


21/57

Oral Sedation Rationale


! Medically compromised patients

! Contraindication?!

Maybe, maybe not! Stress reduction protocol

! Remember: The wholetreatment plan doesnt need to be done at onceespeciallyif the patient isnt doing well

! Use with care!

Go low and go slow


22/57

IV Sedation Rationale

! Benzodiazepine (Solo Agent)

! Diazepam

!

Midazolam

! May be sufficient for some patients depending on theprocedure/situation

!

Anxiety! Minor procedures


23/57

IV Sedation Rationale

! Match the plan to the procedure

! Shorter procedures = midazolam

!

Longer procedures = diazepam (+ midazolam)


24/57

IV Sedation Rationale:

Diazepam verses Midazolam

Diazepam Midazolam

! Dosing:

!

Initial 2.5 mg bolus! Typical dose: 5-15 mgs

! Max: 30 mgs

! Onset: ~1-2 minutes

!

Peak effect: 3-5 minutes

! Dosing:

!

Initial 1 mg bolus! 0.3 mg/kg

! Typical dose: 2-10 mgs

! Max: 20 mg


!

Peak effect: 3-5 minutes

Titrate to desired level of sedation. Give AMPLE time BEFORE redosing


25/57


Combinations

enzodiazepine Narcotic

! Diazepam

!

Midazolam

! Fentanyl

!

Meperidine! Hydromorphone


26/57


Diazepam + Fentanyl

! Duration: Moderate procedures

! Quadrant dentistry

!

~45 minutes

! Ideal for procedures with initial period of stimulationfollowed by mild/minimal stimulation

!

Periodontal surgery! Invasive oral surgery


27/57


Diazepam + Fentanyl

! Intraoperative considerations

! Patients will begin wake up around 30-45 minutes!

Possibly avoid redosing if patient is still comfortable

! Postoperative considerations

! Diazepam active metabolites! Hangover possible

! Resedation is possible as well


28/57


Diazepam + Fentanyl

Diazepam Fentanyl

! Dosing:

!

2-10 mgs! Max: 30 mgs

! Onset: 3-5 minutes

!

Titrate to desired level ofsedation. Give AMPLE

time BEFORE redosing

! Dosing:

!

1-2 mcg/kg! Onset: ~60 seconds

! Start with 1 mcg/kg, add

remaining dose if needed! Helps reduce risk of apnea,

chest wall rigidity


29/57


Diazepam + Hydromorphone (Dilaudid)

! Duration: Moderate-long procedures

!

Prolonged action of hydromorphone! Extended analgesic coverage

! Ideal for procedures where postoperative pain is likely

!

Invasive oral surgery! Periodontal surgery


30/57


Diazepam + Hydromorphone (Dilaudid)

! Dosing:

! Diazepam!

Start 2.5 mg, wait 3-5 minutes before redosing! Hydromorphone

! Start with 0.1-0.2 mg

! Wait ~5 minutes before redosing

!

Titrate to required level of sedation! Anxiolysis

! Analgesia


31/57


Diazepam + Meperidine

! Historically used combination

! Not commonly used anymore

! Meperidine

! Unwanted side effects! Tachycardia

! Risk of serotonin toxicity

!

Risk of seizures (proconvulsant)


32/57


Diazepam + Meperidine

! Phased out of most hospitals

! Still available at Wishard

!

Not available at Clarian/IU Health

! Replaced by cleaner alternatives

! Fentanyl


33/57


Midazolam + Fentanyl

! Extremely common combination

!

Moderate duration! Matches well with typical dental procedures

! Initial dose: ~30-45 minutes of sedation

!

Rapid onset & peak effect! Titration is easily accomplished


34/57



Midazolam Fentanyl

! Dosing:! Initial 1 mg bolus

!

0.3 mg/kg


! Peak effect: 3-5 minutes

!

Titrate to desired level ofsedation. Give AMPLEtime BEFORE redosing

! Dosing:

! 1-2 mcg/kg

! Onset: ~60 seconds

! Start with 1 mcg/kg, add

remaining dose if needed! Helps reduce risk of apnea,

chest wall rigidity


35/57



! Minimal postoperative concerns

! No clinically significant active metabolites

! Minimal concerns of resedation

!

Minimal hangover


36/57


Guidelines

!

Rule #1: Go low!!Rule #2: Go slow!

! You can ALWAYS give more

!

But you CANT take it away onceyouve given it..


37/57

Preoperative Instructions

! Review with patients during consult

!

Give patients a hard copy! Include any special instructions

! Hold your multivitamin that morning,

! Take half of your regular insulin

! Be sure to bring your inhaler

!

Bring your CPAP machine


38/57

NPO Guidelines and Oral Medications

! Is it a NPO violation if patients take their regular oralmedication?

! No, as long as.

! 30-60 minutes prior to the appointment

! Taken with a clear fluid


39/57


! What about patients require taking meds with applesauce?

! Common with mentally disabled patients

! Technically a violation, but we accept the risk

! Minimize risk

! Have patients take meds early as possible! 2-4 hours prior to appointment?


40/57


! What about oral premedications?

! Antibiotic premeds

!

Oral sedatives

! Not a violation

! Part of the anesthetic/surgical plan


41/57


! Review NPO guidelines verbally and in writing

! It really does mean NOTHING by mouth

!

Concept:! Reduction in stomach contents

! Volume

! Acidity

! Decreased risk of pulmonary complications if aspirated


42/57

Current NPO Guidelines

! 2 hours

! Clear liquids

! Examples

! Water

! Fruit juices WITHOUT pulp

!

Black coffee! Clear tea

! Carbonated beverages


43/57


! 4 hours

! Breast milk ONLY


44/57


! 6 hours

! Infant formula

!

Non-human milk! Light meal

! Dry toast and clear liquids


45/57


! Meals that include fatty or fried foods or meat may prolonggastric emptying time

!

8+ hours?!

Increased aspiration risk


46/57

Current NPO Guidelines:

Delayed Gastric Emptying

! Concern with certain medical conditions

! Obesity

!

Diabetes mellitus

! Prolong NPO time

! Reduce aspiration risk


47/57

Preoperative Instructions:

Patient Escort

! Escort is responsible for:

! Getting patient home safely

!

Ensuring the patient DOES NOT drive


48/57

Preoperative Instructions:

Patient Escort

! Ideally:

! Arrives with the patient

!

Stays in the office! Is capable of caring for the patient once home

! Postop instructions

! Postop pain meds?


49/57


! Wear loose fitting clothes

!

No:! Makeup

! Mascara

! Contact lenses

!Jewelry

! Perfume


50/57

Postoperative Instructions:

Discharge Criteria

! Awake, responsive and oriented

! Adequately returned to baseline

!

Peak effect of sedatives

! Minimal/no PONV

! Controlled

! Postoperative pain under control

! Local anesthesia


51/57


Discharge Criteria

! Vital signs stable

! 20% of baseline! Blood pressure

! Pulse

! Adequate ventilation and oxygenation

! SpO2 > 90%

!

Should be back to baseline!


52/57


Discharge Criteria

! Written postoperative instructions given to patient/escort

!

Discuss any concerns/answer all questions

! Document who patient left the office in care of


53/57


Discharge Criteria

! Escort patients directly to their car, rather than dischargethem directly from the chair.

!

Helps prevent any falls, injuries


54/57

Postoperative Instructions

! http://www.youtube.com/watch?v=txqiwrbYGrs&feature=related


55/57


Common Directions

! Clear liquids, advance slowly as tolerated

! Avoid fatty or greasy meals

! Stay well hydrated and resume regular meds

! Go home and rest

!

Do NOT drive! Do NOT make any big decisions


56/57


Common Directions

! Contact the office if:! Irretractable PONV

! Oral ondansetron

!

Rectal promethazine! Any other concerns or questions

! Patients need to have a method to contact you after asedation/surgery with complications! It is NOT acceptable to tell patients to just go to the hospital

! 911 is ok if life threatening


57/57

Questions???

! Thanks!!

sedation techniques

Documents