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CONSCIOUS SEDATION FOR DENTAL PROCEDURES. Level of Sedation Awake Conscious sedation ( sedoanalgesia) Deep sedation General anesthesia.

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Presentation on theme: "CONSCIOUS SEDATION FOR DENTAL PROCEDURES. Level of Sedation Awake Conscious sedation ( sedoanalgesia) Deep sedation General anesthesia."— Presentation transcript:

1 CONSCIOUS SEDATION FOR DENTAL PROCEDURES

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 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 Anxiolysis Moderate Sedation 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 A controlled state of depressed consciousness accompanied by a partial loss of protective reflexes and protective reflexes and the ability to respond appropriately to verbal commands 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 The elimination of all sensation accompanied by the loss of consciousness

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

9 Stages of General Anesthesia Stage IV Stage IV Medullar paralysis Medullar paralysis

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

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

12 Diphenhydramine Antihistamine that works at H-1 receptors. Antihistamine that works at H-1 receptors. Used for mild sedation & its antihistamine properties. Used for mild sedation & its antihistamine properties. May cause paradoxical excitement. May cause paradoxical excitement. May produce hypotension, tachycardia, and urinary retention. May produce hypotension, tachycardia, and urinary retention. Use with caution in infants and young children. Use with caution in infants and young children.

13 Provider Responsibilities Provider Responsibilities Pre-Procedure Patient Assessment Pre-Procedure Patient Assessment Vital Signs Vital Signs Allergies Allergies Contacts/Dentures Contacts/Dentures NPO status NPO status Air way Air way Changes in medical history Changes in medical history URI URI Hospitalizations Hospitalizations Sick family members 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. 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. 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. 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 Pediatric patients Not “little adults” Not “little adults” Geriatric patients Geriatric patients Unique subclass of patients with physiological changes complicating treatment Unique subclass of patients with physiological changes complicating treatment

18 “Show Stoppers” Food or fluid intake 6 hours prior to surgery Food or fluid intake 6 hours prior to surgery Clear fluid intake within 2 hours of surgery Clear fluid intake within 2 hours of surgery Can read newspaper print when looking through liquid Can read newspaper print when looking through liquid Recent alcohol ingestion Recent alcohol ingestion Recreational drug use Recreational drug use Pregnancy Pregnancy Thyroid Dysfunction Thyroid Dysfunction

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

20 Provider Responsibilities Provider Responsibilities Pre-Procedure Patient Assessment Pre-Procedure Patient Assessment Informed Consent Informed Consent Escort Present Escort Present Establishes patient’s mental status Establishes patient’s mental status Under the influence of alcohol or drugs Under the influence of alcohol or drugs Oriented to person, place, time Oriented to person, place, time Documentation Documentation

21 A.S.A physical status classification Class I A normal, healthy patient. Class I A normal, healthy patient. Class II A patient with mild systemic disease. Class II A patient with mild systemic disease. Class III A patient with severe 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 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. Class V A moribund patient who is not expected to survive without operation.

22 Provider Responsibilities Provider Responsibilities Intraoperative Responsibilities Intraoperative Responsibilities Informed consent signed prior to sedation Informed consent signed prior to sedation Name, dose, route and time of all medications documented Name, dose, route and time of all medications documented Procedure begin and end times Procedure begin and end times Prior adverse reactions Prior adverse reactions Pre-medication time and effect Pre-medication time and effect

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

24 Provider Responsibilities Provider Responsibilities Post-operative Responsibilities Post-operative Responsibilities Vital Signs at least every 5 minutes Vital Signs at least every 5 minutes BP BP Heart Rate Heart Rate Respiratory Rate Respiratory Rate Oxygen Saturation Oxygen Saturation Level of Consciousness Level of Consciousness Sedated patients must be continuously monitored until discharged Sedated patients must be continuously monitored until discharged

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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. 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) Specifically mean arterial pressure (MAP) MAP MAP Systolic BP – Diastolic BP/3 + Diastolic BP Systolic BP – Diastolic BP/3 + Diastolic BP Also written as Diastolic BP + 1/3 Pulse Pressure Also written as Diastolic BP + 1/3 Pulse Pressure Normal Normal Body loses auto regulatory capacity at a MAP less than 50 or greater than 150 Body loses auto regulatory capacity at a MAP less than 50 or greater than 150

32 Heart Rate Normal range Normal range 60-90

33 Respiratory Rate Normal range per minute Normal range per minute

34 Oxygen Saturation Must be greater than 90% Must be greater than 90% Supplemental oxygen via nasal canula Supplemental oxygen via nasal canula Initially 2-3 liters/minute 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 LowHigh Systolic BP85150 Diastolic BP50100 Rate BPM50110 SP O292100

37 Level of Consciousness Must be able to respond to verbal stimuli by the surgeon in the clinic 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 May be greatly sedated or unable to arouse by verbal stimuli in the operating room

38 Provider Responsibilities Provider Responsibilities Post-operative Responsibilities Post-operative Responsibilities ALDRETE Post-Operative Scoring System ALDRETE Post-Operative Scoring System A cumulative score of 8 or above is necessary for discontinuation of monitoring 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 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 Sum of standardized measurements of movement, respiration, circulation, color and level of consciousness

39 Movement Move all 4 extremities 2 Move all 4 extremities 2 Move 2 extremities1 Move 2 extremities1 No control 0 No control 0

40 Respiration Breathe deep and cough2 Breathe deep and cough2 Dyspnea1 Dyspnea1 No respirations 0 No respirations 0

41 Circulation BP +/- 20% pre-sedation level2 BP +/- 20% pre-sedation level2 BP +/ % pre-sedation level1 BP +/ % pre-sedation level1 BP +/- > 50% pre-sedation level 0 BP +/- > 50% pre-sedation level 0

42 Consciousness Fully alert2 Fully alert2 Arousable1 Arousable1 No response0 No response0

43 Color Pink2 Pink2 Pale, Dusky, Blotchy1 Pale, Dusky, Blotchy1 Cardboard0 Cardboard0

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

45 Valium (Diazepam) Benzodiazepine Benzodiazepine Produces sleepiness and relief of apprehension Produces sleepiness and relief of apprehension Onset of action 1-5 minutes Onset of action 1-5 minutes Half-life Half-life 30 hours 30 hours Active metabolites Active metabolites Average sedative dose Average sedative dose mg mg

46 Midazolam (Dormicom) Midazolam (Dormicom) Short acting benzodiazepine Short acting benzodiazepine 4 times more potent than Valium 4 times more potent than Valium Produces sleepiness and relief of apprehension Produces sleepiness and relief of apprehension Onset of action 3-5 minutes Onset of action 3-5 minutes Half-life Half-life hours hours Average sedative dose Average sedative dose mg mg

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

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

49 Fentanyl (Sublimaze) Narcotic/Opioid agonist Narcotic/Opioid agonist 100 times more potent than Morphine 100 times more potent than Morphine Pain attenuation and some sedation Pain attenuation and some sedation Onset of action around 1 minute Onset of action around 1 minute Half-life Half-life minutes minutes Average dose Average dose 0.05 – 0.06 mg 0.05 – 0.06 mg

50 The Key to Sedation Local Anesthesia Local Anesthesia If a poor local anesthetic block has been given, the patient will continue to feel pain throughout the procedure 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 Likely to be seen in scenarios where deeper levels of sedation are being performed Propofol (Diprivan) Propofol (Diprivan) Robinul (Glycopyrrolate) Robinul (Glycopyrrolate)

52 Propofol (Diprivan) Intravenous anesthetic/sedative hypnotic Intravenous anesthetic/sedative hypnotic Sedative, anesthetic and some antiemetic properties Sedative, anesthetic and some antiemetic properties Onset of action within 30 seconds Onset of action within 30 seconds Half-life Half-life 2-4 minutes 2-4 minutes Average sedative dose Average sedative dose Varies Varies

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

54 METHODS Sedo –analgesia Sedo –analgesia Midazolam Midazolam Fentanyl Fentanyl Ultra light anesthesia Ultra light anesthesia Diprivan Diprivan Ketamine Ketamine R.A R.A Nitrous oxide 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 % Moderate analgesia % Dissociative analgesia % Near complete amnesia % Light anesthesia.

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

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

60 Medical Emergency Know how to prevent, recognize, and treat syncope (fainting) Know how to prevent, recognize, and treat syncope (fainting) Supplemental O2 Supplemental O2 Elevation of lower extremities Elevation of lower extremities Trendelenburg Trendelenburg Be prepared to assist in airway management Be prepared to assist in airway management

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

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

63 Flumazenil (Romazicon) Benzodiazepine antagonist Benzodiazepine antagonist Versed reversal agent Versed reversal agent Initial dose – 0.2mg Initial dose – 0.2mg May repeat at 1 minute intervals to dose of 1mg May repeat at 1 minute intervals to dose of 1mg Onset of action within 1-2 minutes Onset of action within 1-2 minutes Must monitor for re-sedation Must monitor for re-sedation May be repeated at 20 minute intervals as needed May be repeated at 20 minute intervals as needed

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

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

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

67 Atropine Significant bradycardia or asystole Significant bradycardia or asystole Slow heart beat or NO heartbeat Slow heart beat or NO heartbeat Anticholinergic Anticholinergic Initial dose 0.25 – 1.0 mg Initial dose 0.25 – 1.0 mg May repeat every 3-5 minutes May repeat every 3-5 minutes Maximum total dose.03 mg/kg Maximum total dose.03 mg/kg

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

69 Questions


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