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CONSCIOUS SEDATION FOR DENTAL PROCEDURES

CONSCIOUS SEDATION FOR DENTAL PROCEDURES. Level of Sedation. Awake Conscious sedation ( sedoanalgesia) Deep sedation General anesthesia. Conscious Sedation.

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CONSCIOUS SEDATION FOR DENTAL PROCEDURES

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  1. CONSCIOUS SEDATION FOR DENTAL PROCEDURES

  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 patient’s mental status • Under the influence of alcohol or drugs • Oriented to person, place, time • Documentation

  21. A.S.Aphysicalstatus 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. 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.

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

  27. FACILITIES (3) • Emergency drugs should include at least the following: • Adrenaline, atropine • Dextrose 50% • Lignocaine • Naloxone, Flumazenil

  28. MONITORING Pulse oxymeter B Blood pressure ECG Capnometry . .

  29. 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

  30. 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

  31. Heart Rate • Normal range 60-90

  32. Respiratory Rate • Normal range 10-16 per minute

  33. Oxygen Saturation • Must be greater than 90% • Supplemental oxygen via nasal canula • Initially 2-3 liters/minute

  34. OXYGENATION Degrees of hypoxemia occur frequently during intravenous sedation without oxygen supplementation. Oxygen administration Pulse oxymetry

  35. Recommended Alarm Limits • LowHigh • Systolic BP 85 150 • Diastolic BP 50 100 • Rate BPM 50 110 • SP O2 92 100

  36. 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

  37. 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

  38. Movement • Move all 4 extremities 2 • Move 2 extremities 1 • No control 0

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

  40. Circulation • BP +/- 20% pre-sedation level 2 • BP +/- 21-50% pre-sedation level 1 • BP +/- > 50% pre-sedation level 0

  41. Consciousness • Fully alert 2 • Arousable 1 • No response 0

  42. Color • Pink 2 • Pale, Dusky, Blotchy 1 • Cardboard 0

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

  44. 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

  45. 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

  46. Buccal Midazolam • Concentrated formulation – 10mg/ml • Produced by Special Products • Formulated for use in Epileptic Patients

  47. Demerol (Pethidine) • Narcotic • Pain attenuation and some sedation • Onset of action • 3-5 minutes • Half-life • 30-45 minutes • Average dose • 20-50 mg

  48. 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

  49. 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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