Intravenous Sedation

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CONSCIOUS SEDATION FOR DENTAL PROCEDURES by Dr
. Adel Makhdoom Anesthesia Consultant
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Level of Sedation

• Awake
• Conscious sedation ( sedoanalgesia)
• Deep sedation
• General anesthesia

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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

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Consciousness

• Protective reflexes
• Patent air way
• Verbal contact

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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

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C.N.S.Depressants

• Narcotics
• Tranquilizers
• Sedatives
• Hypnotics
• Induction agents
• Anticonvulsants

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General Anesthesia

• The elimination of all sensation accompanied by
  the loss of consciousness

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Stages of General Anesthesia

• Stage I
• Analgesia
• Stage II
• Delirium
• Stage III
• Surgical anesthesia
• 4 planes of surgical anesthesia

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Stages of General Anesthesia

• Stage IV
• Medullar paralysis

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Provider Responsibilities

• Pre-Procedure preparation
• Pre-Procedure Patient Assessment
• Intraoperative Responsibilities
• Post-operative Responsibilities

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Provider Responsibilities

• Pre-Procedure preparation
• Equipment
• Instruments
• Venipuncture
• Monitors
• Emergency Supplies
• Crash Cart
• Cardiac Monitor
• Medications

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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.

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Provider Responsibilities

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

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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.

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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.

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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.

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Special Considerations

• Pediatric patients
• Not little adults
• Geriatric patients
• Unique subclass of patients with physiological
  changes complicating treatment

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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

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Show Stoppers

• Recent asthma attack or respiratory failure
• Treatment with MAO inhibitors
• Tricyclic Antidepressants
• Adrenal Dysfunction
• Renal Dysfunction

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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

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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.

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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

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Provider Responsibilities

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

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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

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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.
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FACILITIES (2)
Adequate equipments for artificial ventilation
and airway management - Appropriate drugs
for cardiopulmonary resuscitation. -
Intravenous equipment. - Pulse oxymeter.
- Defibrillator.
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FACILITIES (3)

• Emergency drugs should include at least the
  following
• Adrenaline, atropine
• Dextrose 50
• Lignocaine
• Naloxone, Flumazenil

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MONITORING
Pulse oxymeter B
Blood pressure ECG
Capnometry   . .
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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
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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

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Heart Rate

• Normal range 60-90

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Respiratory Rate

• Normal range 10-16 per minute

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Oxygen Saturation

• Must be greater than 90
• Supplemental oxygen via nasal canula
• Initially 2-3 liters/minute

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OXYGENATION
Degrees of hypoxemia occur
frequently during intravenous
sedation without oxygen supplementation.
Oxygen administration Pulse
oxymetry
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Recommended Alarm Limits
Low High Systolic BP 85 150 Diastolic
BP 50 100 Rate BPM 50 110 SP O2 92 100
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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

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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

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Movement

• Move all 4 extremities 2
• Move 2 extremities 1
• No control 0

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Respiration

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

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Circulation

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

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Consciousness

• Fully alert 2
• Arousable 1
• No response 0

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Color

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

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METHODS

• Sedo analgesia
• Midazolam
• Fentanyl
• Ultra light anesthesia
• Diprivan
• Ketamine
• R.A
• Nitrous oxide

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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

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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

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Buccal Midazolam

• Concentrated formulation 10mg/ml
• Produced by Special Products
• Formulated for use in Epileptic Patients

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Demerol (Pethidine)

• Narcotic
• Pain attenuation and some sedation
• Onset of action
• 3-5 minutes
• Half-life
• 30-45 minutes
• Average dose
• 20-50 mg

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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

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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

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Additional Medications

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

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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

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Robinul (Glycopyrrolate)

• Anticholinergic
• Heart rate increases
• Salivary secretions decrease
• Dose 0.1-0.2 mg
• Onset of action within 1 minute

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METHODS

• Sedo analgesia
• Midazolam
• Fentanyl
• Ultra light anesthesia
• Diprivan
• Ketamine
• R.A
• Nitrous oxide

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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.
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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
.
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Nitrous oxide
6 - 25---------------------Moderate
analgesia. 26 - 45---------------------Dissociati
ve analgesia. 46 - 65---------------------Near
complete amnesia. 66 - 80---------------------Lig
ht anesthesia.
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Medical Emergency

• Syncope
• Hypoglycemia
• Hypotension
• Hypertension
• Bronchospasm

• Laryngospasm
• Apnea
• Myocardial infarction
• Stroke

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Medical Emergency

• Know when and how to activate a Code Blue
• Location of Crash Cart
• Medications
• Monitors
• Location of emergency medications
• BLS

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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

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Emergency Drugs

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

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Emergency Drugs

• Flumazenil (Romazicon)
• Naloxone (Narcan)
• Esmolol (Brevibloc)
• Ephedrine
• Epinephrine
• Atropine
• Dextrose 50
• Lignocaine

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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

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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

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Esmolol (Brevibloc)

• Antihypertensive
• Beta blocker
• Initial dose 0.25 1.0 mg/kg over 30 seconds
• Short half-life of approximately 10 minutes

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Ephedrine

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

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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

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Epinephrine

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

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Questions