Conscious Sedation

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

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

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. Drugs 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

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 AgentsPropofol • 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

42. Anesthetic AgentsKetamine • 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 CONFUSION

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