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 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 85 150 Diastolic BP 50 100 Rate BPM 50 110 SP O2 92 100

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

Consciousness Fully alert 2 Arousable 1 No response 0

Color Pink 2 Pale, Dusky, Blotchy 1 Cardboard 0

METHODS Sedo –analgesia Ultra light anesthesia R.A Midazolam Fentanyl 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 Ultra light anesthesia R.A Midazolam Fentanyl 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 Initial dose – 0.4mg 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 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

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

Questions