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Conscious Sedation Dr. Rahaf Al-Habbab BDS. MsD. DABOMS Diplomat of the American Boards of Oral and Maxillofacial Surgery.

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Presentation on theme: "Conscious Sedation Dr. Rahaf Al-Habbab BDS. MsD. DABOMS Diplomat of the American Boards of Oral and Maxillofacial Surgery."— Presentation transcript:

1 Conscious Sedation Dr. Rahaf Al-Habbab BDS. MsD. DABOMS Diplomat of the American Boards of Oral and Maxillofacial Surgery

2 Why Do Most People Avoid Going To The Dentist? FEAR

3 Office Anesthesia To facilitate surgery and patient comfort Amnesia Analgesia Conscious Sedation Ambulatory General Anesthesia (No Intubation) Hypnosis Immobilization

4 Ambulatory General Anesthesia Selective use of sedative and anesthetic agents designed to produce a brief period of anesthesia and to facilitate a rapid recovery period after the termination of the procedure Patient has a brief post-operative recovery period Patient can ambulate after the termination of anesthesia

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6 IV Sedation A 30 year-old male patient, comes to your office for consultation for extraction of hi maxillary and mandibular third molars, He asked to be sedated. How will you assess this patient?

7 Pre-Operative Evaluation PMH Medication, Allergies ASA Classification Vital Signs: BP, Pulse, RR, Oxygen Saturation, Height, Weight Physical Exam Airway Exam

8 Pre-Operative Evaluation PMH Medication, Allergies ASA Classification Vital Signs: BP, Pulse, RR, Oxygen Saturation, Height, Weight Physical Exam Airway Exam

9 ASA Classification General Pre-Anesthetic Evaluation American Society of Anesthesiologists (ASA) Physical Status Classes ASA I A normal healthy patient ASA II A patient with mild systemic disease or significant health risk factor ASA III A patient with severe systemic disease that is not incapacitating ASA IV A patient with sever systemic disease that is a constant threat to life ASA V A patient who is not expected to survive without the operation ASA VI A declared brain dead patient whose organs are being Removed for donor purposes

10 Pre-Operative Evaluation PMH Medication, Allergies ASA Classification Vital Signs: BP, Pulse, RR, Oxygen Saturation, Height, Weight Physical Exam Airway Exam

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12 Pre-Operative Evaluation PMH Medication, Allergies ASA Classification Vital Signs: BP, Pulse, RR, Oxygen Saturation, Height, Weight Physical Exam Airway Exam

13 Airway Mallampati Classification

14 Airway Class I Facial pillars, soft palate, and uvula are visible

15 Airway Class II Facial pillars, soft palate, and part of the uvula

16 Airway Class III Soft Palate, and Base of Uvula

17 Airway Class IV Only soft palate is visible Intubation is predicted to be difficult

18 Airway Airway Evaluation Thyromental distance not less than 3-4 finger width

19 Airway Predictors of a difficult Airway: Obesity Mouth opening Thyromental distance Mental-hyoid distance Retrognathia

20 Pre-operative Instructions Why “NPO” Guidelines? To avoid aspiration pneumonia To prevent foreign body obstruction

21 NPO Guidelines Guidelines for pre-operative fasting No solids on day of surgery Solids: 6—8 hours prior to surgery Clear liquids: 2 hours prior to surgery Oral Medications: 1 hour with sip of water

22 Equipments

23 IV Puncture Butterfly Needles: Short metal needle Easy to place Winged tabs permit easy securing point Short needle reduces patient anxiety

24 IV Puncture Angiocatheter Indwelling peripheral catheter Catheter over needle Needle serve as an introducer Variable length and gauges of needles

25 IV Fluids IV Fluids provide hydration Administration of anesthetic agents and emergency medication

26 IV Fluids Choose what you need and need what you choose

27 IV Puncture The preferred site is: Antecubital fossa Brachial Artery Other Sites: Hand, leg, neck The hand is painful and some drugs cause burning (e.g. diazepam, propafol)

28 Monitoring

29 BP HR Pulse Oximetry RR 3 Lead ECG End Tidal CO2

30 Monitoring Definition: continuous observation of data to evaluate physiologic Function Purpose: To permit prompt recognition of a deviation From normal, so corrective therapy can be implemented before morbidity ensures.

31 Monitoring Respiratory Monitoring 1- Oxygen Monitoring Pulse Oximetry

32 Monitoring 2- Ventilatory Monitoring: Visual inspection (see the chest rise) Pretracheal Stethoscope (precordial) End-tidal CO2

33 Second Part

34 Drugs

35 No drug ever exerts a single action No clinically useful drug is entirely devoid of toxicity

36 Drugs Ideal anesthetic agents for ambulatory general anesthesia: Rapid onset Short duration of clinical effect High clearance rate Minimal tendency for drug accumulation

37 Benzodiazepines Most commonly used Oral, IV, IM The patient maintains his own reflexes May cause respiratory depression in very large doses Effects: Sedation Anxiolysis Antigrade amnesia Diazepam (VALIUM) Midazolam (VERSED) Reversal: Flumazenil

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39 Opioids Alter the sensation and suppress responses associated with certain manipulation (such as elevation of a tooth), which persist despite achievement of a profound nerve block Effects: Analgesia Types: Fentanyl Mepridine Morphine Reversal Naloxon (Narcan)

40 Anesthetic Agents Propofol Dose dependant depression of the central nervous system that give rise to anesthetic effect that ranges from sedation to hypnosis Short acting Widely used in ambulatory general anesthesia

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42 Anesthetic Agents Ketamine A dissociative anesthetic Pharmacological immobilization “chemical straight-jacket” Used as an adjunct to general anesthesia

43 Guedel’s Classification Stage of Analgesia Stage of Delirium Stage of Surgical Anesthesia Respiratory Paralysis

44 Guedel’s Classification Stage of Analgesia Stage of Delirium Stage of Surgical Anesthesia Respiratory Paralysis

45 Guedel’s Classification Stage I: Analgesia Patient is wake and conscious but remains under the drug influence Respiration, eye movement and all protective reflexes are intact Patient will be ideally calm and cooperative Light sedation

46 Guedel’s Classification Stage of Analgesia Stage of Delirium Stage of Surgical Anesthesia Respiratory Paralysis

47 Guedel’s Classification Stage II: Delirium CNS Depression is more pronounced Patient may briefly lose consciousness Respiration may be irregular in early stage II Pupils reactive to light Increased skeletal muscle tone/activity Laryngeal and pharyngeal reflexes increased Entry into stage II is undesirable Patients will likely be hyper-responsive and difficult to manage During induction, stage II is typically bypassed CONFUSIONCONFUSION

48 Guedel’s Classification Stage of Analgesia Stage of Delirium Stage of Surgical Anesthesia Respiratory Paralysis

49 Guedel’s Classification Stage III: Surgical Anesthesia Desired level of anesthesia for major surgical procedures Patient unconscious No response to surgical stimulus (abdominal skin incision) Respiration regular (autonomic and involuntary) Alteration in muscle tone (relaxation) Stage III is characterized by division into several (continuous) planes of anesthesia Differences related to variance in: Respiration Eyeball movement Reflexes Papillary constriction

50 Stage III: Surgical Anesthesia Not an appropriate level of anesthesia for office setting Requires continuous respiratory support/ventilation No protective reflexes Patient will be unresponsive and unarousable Potential for airway obstruction Inability to react to adverse events Potential exists to slide into stage IV with few outwardly visible signs unless carefully monitored

51 Guedel’s Classification Stage of Analgesia Stage of Delirium Stage of Surgical Anesthesia Respiratory Paralysis

52 Stage IV: Respiratory Paralysis OK- NOW YOU ARE IN TROUBLE Onset of medullary depression Result in degradation of autonomic functions Begins with the onset of Respiratory Arrest Ends with Cardiovascular Collapse (late)

53 Conscious Sedation The patient maintain all reflexes The patient can respond to verbal command Drugs are titrated to effect

54 Ambulatory General Anesthesia Diazepam or Midazolam Fentanyl Propofol +/- Kitamine

55 Pediatric Cases Nitrous Oxide Or Oral Midazolam Or IM Ketamine

56 The End


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