assessment for IV Sedation Flashcards
what is the GDC definition of sedation
- “a technique in which the use of a drug or drugs produces a state of depression of the CNS enabling treatment to be carried out,
- but during which communication can be maintained and the modification of the patient’s state of 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”
- but during which communication can be maintained and the modification of the patient’s state of mind is such that the patient will respond to command throughout the period of sedation.
what is involved in sedation assessment
- A full assessment that confirms the treatment required, whether sedation is needed and the preferred technique
Sedation assessment also involves informed consent and the provision of information to the patient which aims to ensure treatment and aftercare are as safe as p
in what 2 ways should the patient be assessed before sedation
- A full assessment that confirms the treatment required, whether sedation is needed and the preferred technique
Sedation assessment also involves informed consent and the provision of information to the patient which aims to ensure treatment and aftercare are as safe as possible
in what 2 ways should the patient be assessed before sedation
Sedation assessment form
Patients for GA attend for pre-assessment in the day surgery unit or hospital and this is carried out by a nurse
can the assessment be carried out on the same day as sedation treatment
no
what is included in the assessment
- History
○ Social
○ Dental
○ Medical- Examination
○ General
○ Oral
○ Vital signs - Treatment Plan
- Consent
Information for patient and escort
- Examination
what elements of a patients social history are relevant for sedation
- Nature of fear
- Anxiety questionnaire
- Occupation
○ Try and determine whether patient can return to work the next day after having sedation but this also depends on what treatment is carried out
§ Eg patient had 4 wisdom teeth removed; wouldn’t recommend they return to work the next day as they will be sore and swollen - Escort
○ Mandatory
○ Need to stay in the building with patient while they are having treatment
○ Need to take the patient home after treatment and stay with them at home until the sedation has worn off - Alcohol
○ Normal alcohol intake - Responsibilities
○ Eg children
○ Elderly relatives need taken care of?
○ Need other measures put into place - Transport
○ Public transport / own transport / taxi - Ages
Extremes of age
recreational drugs taken?
what elements of a patients dental history are relevant for sedation
- Referral source
○ Eg own GDP- Previous bad experience
○ Are they anxious about all treatment or something specific - Previous sedation / GA
○ Any problems
§ Eg if they had GA did it take ages for the patient to wake up - Symptoms
○ Acute
○ Chronic - Proposed procedure
○ Completed within 45 minutes
§ Can top sedation up but it is usually unadvisable to do this
○ Difficult to tolerate
§ Eg some 3rd molars
Ie these patients might usually be perfectly happy to have treatment to be carried out but the procedure means it is causing problems
- Previous bad experience
what elements of a patients medical history are relevant for sedation
fill out MH form
get more information about conditions / on-going treatment / etc
always check drugs - BNF
- drug history
- drug allergy
what effect does almost all drugs have in terms of interaction with midazolam
Almost all drugs increase the sedative effect of midazolam
name drugs which can cause this increase sedative effect of midazolam
○ Alcohol
○ Opiods
○ Erythromycin
○ Antidepressants, antihistamines, antipsychotics
Recreational drugs
what is ASA I
○ Normal healthy patient
○ Non-smoker
○ Minimal alcohol
No medication
what is ASA II
○ Mild systemic disease
○ Current smoker
○ Pregnancy
○ Well-controlled epilepsy
○ Well controlled asthma
○ NIDDM = non-insulin dependent diabetes mellitus
○ BP = 140-159 / 90-94
§ Borderline hypertension
Obesity (BMI: 30-<40)
what is ASA III
Severe systemic disease
Limits activity but not incapacitating
○ IDDM = insulin dependent diabetes mellitus
○ >6/12 (ie more than 6 months) post MI
○ >6/12 post CVA / stroke
○ Stable angina
○ COPD
○ BP = 160-199 / 95 -114
§ Hypertension
○ BMI: >40
Morbidly obese
what is ASA IV
Severe systemic disease
Constant threat to life
○ Unstable angina
§ Has chest pain at rest
○ <3/12 post MI or stenting
○ <3/12 post CVA
○ Severe COPD
○ BP > 200 / 115
Very hypertensive
what is ASA V
○ Moribund
Not expected to live > 24 hours
what is ASA VI
Patient who is brain dead for organ donation
where should ASA I be treated
may be treated in primary care
where should ASA II be treated
may be treated in primary care
where should ASA III be treated
should be secondary care
be cautious with these patients
can be treated in primary care if their disease is relatively stable
where should ASA IV be treated
Must be treated in secondary care
how does sedation affect respiratory disease
- Almost all sedative agents cause respiratory depression
- Normally able to compensate
○ But not always so be careful - Asthma:
○ What drug do they take for their asthma and how often?
§ = finding out how bad their asthma is
○ Have they been hospitalised?
○ Is it exacerbated by stress?
Can have this but have relatively mild asthma most of the time
- Normally able to compensate
what are pharmacodynamic interactions in terms of sedation
- Interactions between drugs which have similar or antagonistic pharmacological effects or S/E’s
- Predictable from pharmacology
○ Antidepressants + BDZ’s
§ Antidepressants will cause respiratory depression and benzodiazepines have a similar effect
Antihypertensives + BDZ’s
- Predictable from pharmacology
what are pharmacokinetic interactions in terms of sedation
- 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 effects small proportion of cases
- Not predictable
what ASA class does pregnancy fall into
ASA II
* Theoretical risks
○ ? Teratogenic
○ ? Sedative effect on baby
○ ? Lactation
* Try and avoid sedation during pregnancy if we can because it is likely to make patients more anxious about the effect it may have on the baby
○ Most people prefer to avoid taking drugs during pregnancy
what is part of the general examination in the sedation assessment
- Signs of anxiety
- Discomfort with surroundings
- Eye contact
- Speech
Vital signs
what are examples of things that the patient can be anxious about
○ Mirror
○ Gloves
○ Radiographs
○ Surgery
○ Chair
§ Being laid back especially
§ Especially common in patients who have been in abusive situations before during their lives; they find the loss of control difficult
Surgeon
what vital signs are checked during the assessment visit
- HR
- BP
- Oxygen saturation
- BMI (= weight (kg) / height (m2) )○ But also for the chair in terms of weight = 28 stones for GDH
§ Some chairs on level 3 only take 23.5 stones
Very important to know patient’s weight because the chair might just stop working and you could be in the middle of a procedure and the patient then needs resuscitated it can be a tricky situation if the chair is broken
what is the cut off BMI weight for sedation
Weight cut off for sedation = BMI = 35Any body over a BMI of 35 and who needs sedation has to go to the royal infirmary for treatment there
Less than 18.5 = underweight
Between 18.5-24.9 = healthy weight
Between 25 - 29.9 = overweight
Over 30 = obese
But also for the chair in terms of weight = 28 stones for GDH
Some chairs on level 3 only take 23.5 stones
what are important principles to remove when treatment planning for sedation
- Avoid overcomplicated treatment
○ Good working time = 45 minutes - Realistic dentistry
○ Need to think that if the patient is very anxious they are probably not going to come back for regular reviews unless they get sedation / probably not going to get other treatment done unless they get sedation - Deal with misconceptions about sedation
○ Loss of consciousness / amnesia
○ Lack of control - Patient will still be conscious so they still can ask you to stop and this should be made clear to the patient during the assessment visit
what is included in the orientation to the sedation setting
- Written pre- and post-op instructions
- Introduction to environment and staff
- Opportunity for questions
- Consent
○ Needs to be informed - Appointment
○ Soon as possible after assessment if possible
Assessment forms, consent forms and information leaflets on Moodle
