conscious sedation for dental procedures
DESCRIPTION
CONSCIOUS SEDATION FOR DENTAL PROCEDURES. Level of Sedation. Awake Conscious sedation ( sedoanalgesia) Deep sedation General anesthesia. Conscious Sedation. - PowerPoint PPT PresentationTRANSCRIPT
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