Assessment for Sedation

Question 1

GDC sedation definition

Answer 1

“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.”​

Question 2

who can assess pts for sedation

Answer 2

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.

Question 3

components of sedation assessment

Answer 3

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

Question 4

who does IV pre-assessment

Answer 4

general nurse in hospital

Question 5

who does IS pre-assessment

Answer 5

combination of dental nurse and dentist, in dental setting

Question 6

aspects covered in assessment for sedation

Answer 6

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

Question 7

aspects of social history to explore for sedation pt

Answer 7

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?
• 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​

Question 8

dental history to cover for sedation pt

Answer 8

• 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

Question 9

medical history to cover for sedation pt

Answer 9

• 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​

Question 10

• 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

Answer 10

Class II

Question 11

• 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

Answer 11

III

Question 12

• unstable angina​ (at rest)
• < 3/12 post. MI or stenting​
• < 3/12 post. CVA​
• severe COPD​
• BP > 200/115​

which ASA class

Answer 12

IV

Question 13

which ASA classes can be tx in primary care

Answer 13

I and II

Question 14

ASA classes requiring secondary care

Answer 14

III and IV

Question 15

sedative drugs affect on respiration

Answer 15

almost all cause respiratory depression

Question 16

check for asthmatic sedative pts

Answer 16

• What drugs do they take for their asthma and how often?​
• Have they been hospitalised?​
• Is it exacerbated by stress​?

Question 17

neurosis is

Answer 17

anxiety and depression

Question 18

psychosis is

Answer 18

schizophrenia

Question 19

recreational drug uses caution for sedation why?

Answer 19

less predictable outcomes

Question 20

pharmcaodynamic interactions

Answer 20

• 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​

Question 21

pharmacokinetic interactions

Answer 21

• 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

Question 22

pregnancy and sedation

Answer 22

avoid

ASA II

theoretical risks on baby - avoid for peace of mind

Question 23

general signs of anxiety to look out for in exam

Answer 23

• Discomfort with surroundings​
• Eye contact​
• Speech​

Question 24

examination of sedation pt components

Answer 24

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​

Question 25

vital signs needed for sedation

Answer 25

• 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

Question 26

BMI less than 18.5

Answer 26

underweight

Question 27

BMI 18.5-24.9

Answer 27

healthy weight

Question 28

BMI 25-29.9

Answer 28

overweight

Question 29

BMI ver 30

Answer 29

obese

Question 30

considerations when tx planning for sedation pt

Answer 30

• 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

Question 31

orienatation of sedation setting for pt

Answer 31

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