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Intravenous Sedation

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CONSCIOUS SEDATION FOR DENTAL PROCEDURES by: Dr. Adel Makhdoom Anesthesia Consultant ... – PowerPoint PPT presentation

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Title: Intravenous Sedation


1
CONSCIOUS SEDATION FOR DENTAL PROCEDURES by Dr
. Adel Makhdoom Anesthesia Consultant
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 patients 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

25
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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/sur
geon 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 80-100
  • 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 10-16 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 85 150 Diastolic
BP 50 100 Rate BPM 50 110 SP O2 92 100
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 2
  • Move 2 extremities 1
  • No control 0

40
Respiration
  • Breathe deep and cough 2
  • Dyspnea 1
  • No respirations 0

41
Circulation
  • BP /- 20 pre-sedation level 2
  • BP /- 21-50 pre-sedation level 1
  • BP /- gt 50 pre-sedation level 0

42
Consciousness
  • Fully alert 2
  • Arousable 1
  • No response 0

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

44
METHODS
  • Sedo analgesia
  • Midazolam
  • Fentanyl
  • Ultra light anesthesia
  • 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
  • 1.2-12.3 hours
  • Average sedative dose
  • 2.5-7.5 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 0.1-0.2 mg
  • Onset of action within 1 minute

54
METHODS
  • Sedo analgesia
  • Midazolam
  • Fentanyl
  • Ultra light anesthesia
  • 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. 26 - 45---------------------Dissociati
ve analgesia. 46 - 65---------------------Near
complete amnesia. 66 - 80---------------------Lig
ht 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
  • Fentanyl reversal agent
  • Initial dose 0.4mg
  • May repeat every 2-3 minutes at doses of 0.4-2mg
  • 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
  • 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
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