Assessment for Intravenous Sedation

Question 1

What is the GDC definition of sedation?

Answer 1

A technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carries out, but during which communication can be maintained and the modification of the patients mind is such that the patient will respond to command throughout the period of sedation. Techniques used should carry a margin of safety wide enough to render unintended loss of consciousness unlikely.

Question 2

What are the sedation guidelines that must be adhered to?

Answer 2

• 2015 RCS
  
  • Standards for Conscious Sedation in the Provision of Dental Care
• 2017 SDCEP
  
  • Conscious Sedation in Dentistry

Question 3

What is the aim of sedation assessment?

Answer 3

To confirm the treatment required, whether sedation is needed and the preferred technique.

• informed consent
• provision of information to patient
• ensures treatment and aftercare are as safe as possible

Question 4

What are the 6 vital factors for assessment for sedation or GA?

Answer 4

• separate visit
  
  • mandatory
  • patient will be less anxious
  • allows time to consider decision
• physiology, pathology and psychology
• essential pre-requisite to treatment
  
  • for patient and dental team
• good, clear communication
  
  • vital for informed consent
• pleasant surroundings and staff
• promptness
  
  • lateness can increase anxiety

Question 5

What are the different components of assessment for IV sedation?

Answer 5

• history
  
  • social
  • dental
  • medical
• examination
  
  • general
  • oral
  • vital signs
• treatment plan
• consent
• information for patient and escort

Question 6

What information must be ascertained from a social history for IV sedation?

Answer 6

• fear/anxiety/phobia
  
  • nature of fear
  • general or specific
  • anxiety questionnaire
• occupation
  
  • return to work
    
    • dependent on treatment type
    • dependent on nature of job
• escort
  
  • mandatory
  • stay for duration of treatment
  • take home afterwards
  • stay until sedation worn off
• alcohol
  
  • no alcohol at time of sedation
• responsibilities
  
  • caring for children/elderly
  • measures put in place
• transport
  
  • private car or taxi
  • no public transport
• age
  
  • extremes of age
    
    • different effects

Question 7

What information must be ascertained from a dental history for IV sedation?

Answer 7

• referral source
  
  • own GDP
  • internal referral
• previous bas experience
  
  • anxious about all treatment
  • anxious about particular procedure
• previous sedation or GA
  
  • any problems?
    
    • long time to wake up after GA

-symtoms
- acute
- chronic

• proposed procedure
  
  • must be able to complete in time
    
    • should avoid topping up
  • difficult to tolerate
    
    • third molar extractions

Question 8

What information must be ascertained from a medical history for IV sedation?

Answer 8

• drug history
  
  • seek confirmation if patient unsure
  • almost all increase midazolam effect
    
    • alcohol
    • opioids
    • erythromycin
    • antidepressents
    • antihistamines
    • antipsychotics
    • recreational drugs
• drug allergy
  
  • benzodiazepines
• previous anaesthetic or sedation
  
  • any issues
• recreational drug use
  
  • interferes with sedative drugs

Question 9

What does ASA stand for in ASA classifications?

Answer 9

American Society of Anaesthesiologists

Question 10

Provide examples of an ASA II patient

Answer 10

• current smoker
• pregnancy
• well controlled epilepsy
• well controlled asthma
• Type II diabetes (NIDDM)
• blood pressure (140-159/90-94)
• obesity (BMI of 30-<40)

Question 11

Provide examples of an ASA III patient

Answer 11

• Type II diabetes (IDDM)
• > 6 months post MI
• > 6 months post CVA
• stable angina
• COPD
• blood pressure (160-199/95-114)
• morbid obesity (BMI >40)

Question 12

Provide examples of an ASA IV patient

Answer 12

• unstable angina
• <3 months post MI or stenting
• <3 months post CVA
• severe COPD
• blood pressure (>200/115)

Question 13

What ASA classifications can be treated in primary care and what must be treated in secondary care?

Answer 13

• primary care
  
  • ASA I
  • ASA II
• secondary care
  
  • ASA III
  • ASA IV

Question 14

Why must caution be taking when performing IV sedation for patients with respiratory disease?

Answer 14

• almost all sedative agents cause respiratory depression
  
  • normally able to compensate
• multiple, regular medications
  
  • more severe disease
• asthma
  
  • what drugs and how regularly?
  • past hospitalisation
  • exacerbated by stress

Question 15

Why must caution be taking when performing IV sedation for patients with psychiatric disease?

Answer 15

• neurosis or psychosis
  
  • determine severity
  • previous treatment
• very difficult group of patients

Question 16

What are pharmacodynamic interactions?

Answer 16

interactions between drugs which have a similar or antagonistic pharmacological effect or side effects

• predictable from pharmacology
  
  • antidepressants + BDZs
    
    • increased respiratory depression
  • antihypertensives + BDZs

Question 17

What are pharmacokinetic interactions?

Answer 17

one drug alters the absorption, distribution, metabolism or excretion of another thereby increasing or reducing the amount of drug available to produce its pharmacological effects

• not predictable
  
  • only affects small portion of cases

Question 18

Why is pregnancy considered ASA II

Answer 18

• theoretical risks
  
  • teratogenic effects
    
    • none proven
      - agent causing foetal abnormality
  • sedative effect on baby
  • lactation
    
    • agent secreted in breast milk
• avoid sedation where possible
  
  • increased anxiety about effect on baby

Question 19

What must a general examination include for a patient for IV sedation?

Answer 19

• signs of anxiety
• discomfort with surroundings
• eye contact
• speech
• vital signs

Question 20

What must a dental examination include for a patient for IV sedation?

Answer 20

• extent may depend on anxiety or phobia
  
  • should be as complete as possible
• possible patient issues
  
  • mirror
  • gloves
  • radiographs
  • surgery
  • chair laid back
    
    • abuse patients
  • surgeon

Question 21

What vital signs must be assessed in assessment for IV sedation?

Answer 21

• heart rate
  
  • pulse oximeter
• blood pressure
  
  • blood pressure cuff
• oxygen saturation
  
  • pulse oximeter
• BMI
  
  • underweight = <18.5
  • healthy weight = 18.5-24.9
  • overweight = 15-29.9
  • obese = >30

Question 22

What is the weight cut off for sedation?

Answer 22

• BMI 35
• 28 stone in GDH, above must be in royal infirmary

Question 23

What factors influence treatment planning for IV sedation?

Answer 23

• discussion with patient
  
  • and family if appropriate
• avoid overcomplicated treatment
  - 45 minutes working time
• realistic dentistry
• deal with misconceptions of sedation
  
  • loss of consciousness/amnesia
    
    • amnesia is likely side effect
  • lack of control
    
    • patient can still ask to stop

Question 24

What does orientation to the sedation session involve?

Answer 24

• written pre and post operative instructions
• introduction to environment and staff
• opportunity for questions
  
  • include patients in treatment planning
• consent
• appointment soon after assessment
  
  • prevents overthinking
• assessment forms, consent forma and information leaflets