Assessment for Sedation Flashcards
GDC sedation definition
“A technique in which the the use of a drug or drugs produces a state of depression of the central nervous system 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.”
who can assess pts for sedation
On graduation you need to be competent in the clinical assessment of patients who MAY then go on to have treatment under LA, GA or IV Sedation
- Your job is to make patients aware of these options and discuss whether referral is needed
Adult patients will have the chance to discuss this further if they are referred on
You do not need to be competent at sedation assessment OR in the techniques of IV sedation on graduation.
- If you wish to practice IV sedation after graduation you will NEED to undertake further training.
components of 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 possible
who does IV pre-assessment
general nurse in hospital
who does IS pre-assessment
combination of dental nurse and dentist, in dental setting
aspects covered in assessment for sedation
there are assessment forms
- Separate visit
- less anxious state of mind possible
- cooling off period for them to reflect prior to procedure
- histories
- Physiology, pathology and psychology
- Essential prerequisite to tx for pts and for dental team
- Good clear communication
- consent for explained tx
aspects of social history to explore for sedation pt
Form of anxiety management, not anaesthetic. Need to understand nature of the fear/anxiety
- Nature of fear
- Phobia v Anxiety-covered in yesterday’s lecture
- General v Specific
- Anxiety questionnaire-we don’t currently use one but several are available including MDAS (Modified Dental Anxiety Scale, Humphries et al, 2009-see Moodle)
- Occupation
- Is it appropriate to go back to work next day?
- E.g. teacher, call centre, physical labour
- Extent of tx consider – many XLA?
- Is it appropriate to go back to work next day?
- Escort
- Remain with them until sedation worn off when back at home
- Alcohol
- Responsibilities-e.g. children, elderly relatives – need care in place
- Transport
- Age
- Differing effects of sedation at extremes of age
dental history to cover for sedation pt
- Referral source
- e.g. Own GDP
- Previous bad experience
- Anxious about all tx or just procedure referred for
- Previous sedation / GA
- Any problems?
- Symptoms
- Acute
- Chronic
- Proposed procedure
- Completed within 45 mins
- Difficult to tolerate e.g. some third molars
medical history to cover for sedation pt
- Questionnaires can be used, they are useful as they provide prompts for the patient for things they may not see as relevant
- Similar format to the PMH sheets used for normal treatment
- Remember to go over the history with the patient and ask for more information about any positive responses
- Drug history
- Drug allergy
- Previous anaesthetic / sedation and any issues
- Recreational drug use
If patients are unclear about what drugs they are taking you should seek confirmation
Almost all drugs increase the sedative effect of midazolam
- Alcohol
- Opiods
- Erythromycin
- Antidepressants, Antihistamines, Antipsychotics,
- Recreational drugs
- Current smoker
- Pregnancy
- well-controlled epilepsy
- well-controlled asthma
- NIDDM (non insulin dependent diabetes mellitus, type 2)
- BP = 140-159/90-94 (borderline hypertension)
- Obesity (30 - <40)
which ASA class
Class II
- IDDM (insulin dependent diabetes mellitus, type 1)
- >6/12 post MI
- >6/12 post CVA
- stable angina
- COPD
- BP = 160-199/95-114 (hypertension)
- BMI>40 (morbidly obese)
which ASA class
III
- unstable angina (at rest)
- < 3/12 post. MI or stenting
- < 3/12 post. CVA
- severe COPD
- BP > 200/115
which ASA class
IV
which ASA classes can be tx in primary care
I and II
ASA classes requiring secondary care
III and IV
sedative drugs affect on respiration
almost all cause respiratory depression
check for asthmatic sedative pts
- What drugs do they take for their asthma and how often?
- Have they been hospitalised?
- Is it exacerbated by stress?
neurosis is
anxiety and depression
psychosis is
schizophrenia
recreational drug uses caution for sedation why?
less predictable outcomes
pharmcaodynamic interactions
- Interactions between drugs which have similar or antagonistic pharmacological effects or side effects
- Predictable from pharmacology
- Antidepressants + BDZ’s (cause resp depression)
- Antihypertensives + BDZ’s
pharmacokinetic interactions
- 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
pregnancy and sedation
avoid
ASA II
theoretical risks on baby - avoid for peace of mind
general signs of anxiety to look out for in exam
- Discomfort with surroundings
- Eye contact
- Speech
examination of sedation pt components
geneal signs of anxiety
vital signs
dental exam
- Amount possible may vary if patients is phobic or very anxious but should be as complete as possible
- Ask what is causing them dental anxiety/phobia
- Mirror
- Gloves
- Radiographs
- Surgery
- Chair-being laid back especially
- Surgeon
vital signs needed for sedation
- HR
- BP
- Oxygen saturation
- BMI=weight (kg)/height (m2)
- Weight cut off for sedation (BMI 35) but also for the chair in terms of weight (28 stones for GDH)
- Over these limited à GRI
- Weight cut off for sedation (BMI 35) but also for the chair in terms of weight (28 stones for GDH)
BMI less than 18.5
underweight
BMI 18.5-24.9
healthy weight
BMI 25-29.9
overweight
BMI ver 30
obese
considerations when tx planning for sedation pt
- Take account of all information
- Medical, dental, social
- Discussion with pt and/or family if appropriate
Avoid overcomplicated tx
- good working time 45mins
Realistic dentistry
- esp for phobic pts as unlike to come back for review or further tx etc as need sedation for tx
orienatation of sedation setting for pt
help with anxiety
- Written pre and post op instructions
- Informed Consent
- Introduction to environment and staff
- Opportunity for questions
- Loss of consciousness/amnesia - NO
- Lack of control
- Can ask you to stop during sedation
- Appointment
- Soon after assessment if possible, prevent build up of anxiety
