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Presentation on theme: "CONSCIOUS SEDATION FOR"— Presentation transcript:


2 Level of Sedation Awake Conscious sedation ( sedoanalgesia)
Deep sedation General anesthesia

3 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

4 Consciousness Protective reflexes Patent air way Verbal contact

5 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

6 C.N.S.Depressants Narcotics Tranquilizers Sedatives Hypnotics
Induction agents Anticonvulsants

7 General Anesthesia The elimination of all sensation accompanied by the loss of consciousness

8 Stages of General Anesthesia
Stage I Analgesia Stage II Delirium Stage III Surgical anesthesia 4 planes of surgical anesthesia

9 Stages of General Anesthesia
Stage IV Medullar paralysis

10 Provider Responsibilities
Pre-Procedure preparation Pre-Procedure Patient Assessment Intraoperative Responsibilities Post-operative Responsibilities

11 Provider Responsibilities
Pre-Procedure preparation Equipment Instruments Venipuncture Monitors Emergency Supplies “Crash Cart” Cardiac Monitor Medications

12 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.

13 Provider Responsibilities
Pre-Procedure Patient Assessment Vital Signs Allergies Contacts/Dentures NPO status Air way Changes in medical history URI Hospitalizations Sick family members

14 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.

15 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.

16 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.

17 Special Considerations
Pediatric patients Not “little adults” Geriatric patients Unique subclass of patients with physiological changes complicating treatment

18 “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

19 “Show Stoppers” Recent asthma attack or respiratory failure
Treatment with MAO inhibitors Tricyclic Antidepressants Adrenal Dysfunction Renal Dysfunction

20 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

21 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.

22 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

23 Provider Responsibilities
Intr-aoperative Responsibilities Vital Signs BP Heart Rate Respiratory Rate Oxygen Saturation Level of Consciousness

24 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


26 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.

27 FACILITIES (2) Adequate equipments for artificial ventilation and airway management - Appropriate drugs for cardiopulmonary resuscitation. - Intravenous equipment. - Pulse oxymeter. - Defibrillator.

28 FACILITIES (3) Emergency drugs should include at least the following:
Adrenaline, atropine Dextrose 50% Lignocaine Naloxone, Flumazenil

29 MONITORING Pulse oxymeter B Blood pressure ECG Capnometry .

30 The following values are indicative of the “normal” adult patient
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

31 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 Body loses auto regulatory capacity at a MAP less than 50 or greater than 150

32 Heart Rate Normal range 60-90

33 Respiratory Rate Normal range per minute

34 Oxygen Saturation Must be greater than 90%
Supplemental oxygen via nasal canula Initially 2-3 liters/minute

35 OXYGENATION Degrees of hypoxemia occur frequently during intravenous
sedation without oxygen supplementation. Oxygen administration Pulse oxymetry

36 Recommended Alarm Limits
Low High Systolic BP Diastolic BP Rate BPM SP O

37 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

38 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

39 Movement Move all 4 extremities Move 2 extremities 1 No control

40 Respiration Breathe deep and cough 2 Dyspnea 1 No respirations

41 Circulation BP +/- 20% pre-sedation level 2

42 Consciousness Fully alert 2 Arousable 1 No response 0

43 Color Pink 2 Pale, Dusky, Blotchy 1 Cardboard 0

44 METHODS Sedo –analgesia Ultra light anesthesia R.A Midazolam Fentanyl
Diprivan Ketamine R.A Nitrous oxide

45 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

46 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 hours Average sedative dose mg

47 Buccal Midazolam Concentrated formulation – 10mg/ml
Produced by Special Products Formulated for use in Epileptic Patients

48 Demerol (Pethidine) Narcotic Pain attenuation and some sedation
Onset of action 3-5 minutes Half-life 30-45 minutes Average dose 20-50 mg

49 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

50 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

51 Additional Medications
Likely to be seen in scenarios where deeper levels of sedation are being performed Propofol (Diprivan) Robinul (Glycopyrrolate)

52 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

53 Robinul (Glycopyrrolate)
Anticholinergic Heart rate increases Salivary secretions decrease Dose mg Onset of action within 1 minute

54 METHODS Sedo –analgesia Ultra light anesthesia R.A Midazolam Fentanyl
Diprivan Ketamine R.A Nitrous oxide

55 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.

56 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 .

57 Nitrous oxide 6 - 25%---------------------Moderate analgesia.
% Dissociative analgesia. % Near complete amnesia. % Light anesthesia.

58 Medical Emergency Syncope Hypoglycemia Hypotension Hypertension
Bronchospasm Laryngospasm Apnea Myocardial infarction Stroke

59 Medical Emergency Know when and how to activate a “Code Blue”
Location of Crash Cart Medications Monitors Location of emergency medications BLS

60 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

61 Emergency Drugs These are included for reference only
Dentists should not be administering medications to patients without advanced training in ACLS

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

63 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

64 Naloxone (Narcan) Narcotic antagonist Initial dose – 0.4mg
Fentanyl reversal agent Initial dose – 0.4mg May repeat every 2-3 minutes at doses of mg Monitor for re-sedation

65 Esmolol (Brevibloc) Antihypertensive Beta blocker
Initial dose 0.25 –1.0 mg/kg over 30 seconds Short half-life of approximately 10 minutes

66 Ephedrine Used for hypotension Sympathomimetic Initial dose 5-10mg
Action may not be seen for several minutes

67 Atropine Significant bradycardia or asystole Anticholinergic
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

68 Epinephrine True emergency medication
Administration should be preceded by activation of the emergency response system

69 Questions


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