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BDS4 > CDS Sedation > Flashcards

CDS Sedation Flashcards

1
Q

Special care dentistry

A

Dentistry for those with a disability or activity restriction that directly or indirectly affects their oral health

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2
Q

Problems in providing dental treatment in special care

A

Communication
Anxiety
Moving target
Perception of reality
Previous experience

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3
Q

Possible reasons for involuntary movements

A

Parkinson’s
Learning difficulties
Muscular dystrophy
Cerebral palsy
Multiple sclerosis
Huntingdon’s Chorea
Head injury

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4
Q

Why does Midazolam help with involuntary movements?

A

It is a muscle relaxant

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5
Q

Congenital vs acquired learning difficulties

A

Congenital - syndromic or non-syndromic
Acquired - trauma, infection, cerebral vascular accident, Alzheimer’s

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6
Q

Assessment of pts with involuntary movements

A

Mental and physical status
Anxiety
Pain experience

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7
Q

Assessment of pt with learning difficulties

A

Is behaviour management possible?
Is pharmalogical management needed?
PT understanding?
Pt pain experience?

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8
Q

What to do if a patient is competent to consent but can’t write?

A

Verbal consent, documented in notes

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9
Q

Adults with incapacity certificate

A

Medically qualified or appropriately trained dentists can complete a form allowing treatment for patients not competent to give consent, lasting for up to 36 months, as per the adults with incapacity act 2000 Scotland

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10
Q

Conscious sedation techniques

A

Inhalation
Intravenous
Oral
Transmucosal - rectal, intranasal, sublingual

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11
Q

Choice of sedation depends on

A

Patient cooperation
Degree of anxiety
Dentistry required
Skills of the dental team
Patient’s previous experience
Facilities available
Anaesthetist required?

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12
Q

Advantages of inhalation sedation

A

Useful for anxiety relief
Rapid recovery
Flexible duration

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13
Q

Disadvantages of inhalation sedation

A

Keeping nasal hood in place
Less muscle relaxation
Coordination of nasal breathing when mouth open - cooperation important, understand behavioural management

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14
Q

Advantages of IV sedation

A

Good sedation achieved
Less cooperation needed
Muscle relaxation

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15
Q

Disadvantages of IV sedation

A

Baseline readings
IV cannulation required
Assessing sedation level
Behaviour during recovery
Efficacy swallowing

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16
Q

IV sedation types

A

Midazolam
Propofol
Multiple agent

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17
Q

Safety considerations of IV sedation

A

Swallowing
Airway
Liver
Medical interactions
ASA - american society of anaesthesiologists assessment of health

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18
Q

Advantages of oral/transmucosal sedation

A

Avoids cannulation
Can make induction more pleasant
Better cooperation
Better future behaviour

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19
Q

Disadvantages of oral/transmucosal sedation

A

Baseline readings
Bitter taste/stinging
Lag time
Untitreable
Difficulty monitoring level of sedation
Behaviour in recovery

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20
Q

Possible outcomes from sedation

A

All required treatment could be carried out
Some treatment carried out - rest needs GA
Exam, scale and polish - refer to GA for treatment
Other treatments

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21
Q

Treatment planning for sedation patients

A

Pre sedation exam may not be possible
Ability to cope
Complicated treatment - maintenance in future
Treat the pt NOT the carer
Use sedation because of clinical need

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22
Q

Considerations for GA vs sedation

A

Safety - controlled airway with GA, difficult intubation
Cooperation
Waiting lists and access to services
Pain
Medical history
(Still a need for GA)

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23
Q

Dangerous sedation

A

Bolus sedation
Untrained seditionists
Incorrect doses due to wrong labels or incorrect concentration
Reliance on flumazenil

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24
Q

Types of sedation used in dentistry

A

Inhalation - nitrous oxide
Intravenous - usually midazolam (type of benzodiazepine) cannula in the hand

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25
Q

Reverse midazolam

A

Flumazenil

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26
Q

Average dose of midazolam used in dentistry

A

5-6mg

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27
Q

What can be used before an appt to help anxious patients get there?

A

Pre med diazepam can be used
5mg tablet

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28
Q

Conscious sedation

A

A technique in which the use of a drug or drugs produce a state of depression of the central nervous system enabling treatment to be carried out, but during which verbal contact with the patient is maintained throughout the period of sedation

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29
Q

Complications of cannulation

A

Venospasm
Extravascular injection
Intraarterial injection
Haematoma
Fainting

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30
Q

Complications of drug administration

A

Hyper responders
Hypo responders
Paradoxical reactions
Oversedation
Allergic reactions

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31
Q

Venospasm

A

Disappearing vein, veins collapse at attempted venepuncture
May be accompanied by burning sensation
Associated with poorly visible veins
Worse with repeated attempts, slow puncture or if pt is cold

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32
Q

Extravascular injection

A

Active drug placed into interstitial space
Pain, swelling, delayed absorption
Prevent with good cannulation and a test dose of saline
To treat - remove cannula, apply pressure, reassure

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33
Q

Intra-arteiral injection

A

(when cannulating at elbow)
Pain on venepuncture
Red blood in cannula
Difficult to prevent leaks
Pain radiating distally from site of cannulation
Loss of colour or warmth to limb/weakening pulse
Prevent by avoiding anatomically prone sites such as ACF medial to biceps tendon
Manage by monitoring for loss of pulse, discolouration or going cold. Leave cannula in situ for 5 mins post drug, if no problems remove and if symptomatic leave it in and refer to hospital

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34
Q

Haematoma

A

Due to damage to vein walls at venepuncture if poor technique or at removal of cannula if failure to apply pressure.
Take care with elderly patients
Treat with time, rest, reassurance
If severe use ice pack initially followed by moist heat 20minutes in the hour following
Consider heparin gel

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35
Q

Fainting during IV sedation

A

Anxiety related to venepuncture
Worse if starved
Prevention - topical skin anaesthesia, risk asses first, consider patient positioning
Pt may lose bladder control, if bowel control is lost this is not a faint

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36
Q

Hyper responders to IV sedation

A

Deep sedation with minimal dose, 1-2mg midazolam, often elderly, titrate slowly in 1mg increments

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37
Q

Hypo responders to IV sedation

A

Little sedative effect with large dose
Check cannulation
May be due to tolerance - BZD users, cross tolerance
Idiopathic
Threshold to abandon is unknown

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38
Q

Paradoxical reactions to IV sedation

A

Unexpected reactions
Appear to sedate normally, react extremely to all stimuli, relax when stimuli removed
Check for failure of LA
DO NOT ADD SEDATIVE
Find other management technique
Beware with teenagers

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39
Q

Oversedation with IV

A

Loss of responsiveness, respiratory depression, loss of ability to maintain airway, respiratory arrest
STOP procedure
Try to rouse pt, ABC, if no response to stimulation reverse with flumazenil 200micrograms then 100microgram increments at minute intervals
Watch for 1-4 hours
Manage respiratory depression by checking oximeter, stimulate pt, ask to breathe, supplemental oxygen nasal cannulae 2L per min

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40
Q

How to manage respiratory depression during IV sedation

A

Check oximeter
Stimulate pt
Ask to breathe
Supplemental oxygen nasal cannulae 2L per minute
Reverse with flumazenil

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41
Q

Half life of midazolam

A

Elimination half life of midazolam is 1-2 hours so can be in system for 12 hours

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42
Q

Oversedation during inhalation sedation

A

Turn it off, if pt comes round decrease by 5-10% before turning back on
Do not remove nose piece

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43
Q

Management of patient panic during inhalation sedation

A

Reassure
If pt can not cope abort

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44
Q

Signs of nitrous oxide overdose

A

Pt discomfort
Lack of pt cooperation
Mouth breathing
Giggling
Nausea
Vomiting
Loss of consciousness

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45
Q

Concentration of Nitrous oxide given in inhalation sedation

A

70%
30% oxygen

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46
Q

How can oversedation happen?

A

Initially by misjudging the dose
Later - traumatic procedure over, mouth breathing ceases

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47
Q

GDC definition of sedation

A

A technique in which the use of a drug or drugs produces a state of depression of the CNS, enabling treatment to but 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

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48
Q

Guidelines for sedation

A

Standard for conscious sedation in the provision of Dental Care 2015
SDCEP Conscious sedation in dentistry 2017
Both very similar in content and set out the requirements for carrying out dental sedation safely, including the required training

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49
Q

GDP role in sedation

A

Be competent in the clinical assessment of patients who may then go one to have treatment under LA, GA or IV sedation
Make patients aware of these options and discuss whether a referral is needed

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50
Q

What is sedation assessment for?

A

Full assessment that confirms the required treatment, whether sedation is needed and the preferred technique. Involves informed consent and provision of information to the patient to ensure that aftercare and treatment are as safe as possible

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51
Q

Essential considerations for assessment for sedation

A

Essential prerequisite
Separate visit
Physiology, pathology and psychology
Good clear communication
Pleasant surroundings and staff
Promptness

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52
Q

Assessment appointment includes

A

History (social, dental, medical)
Examination (general, oral, vital signs)
Treatment plan
Consent
Information for patient and escort

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53
Q

Social history for sedation assessment

A

Try to determine nature of fear, phobia vs anxiety, general vs specific
Anxiety questionnaire such as MDAS could be used
Occupation
Escort
Alcohol
Responsibilities such as children
Transport
Age

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54
Q

Dental history for sedation assessment

A

Referral source
Previous bad experience
Previous sedation/GA and any problems
Symptoms - acute or chronic
Proposed procedure

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55
Q

How long is the optimal working time under IV sedation?

A

45 minutes

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56
Q

Medical history for sedation assessment

A

Similar format to PMH for normal treatment - can use questionnaires as they provide prompts for the patient for things they may not see as relevant
Always check drugs
Drug history/drug allergies/previous anaesthetic/sedation

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57
Q

Why is a medical history so important for sedation assessment?

A

Drug interactions
Almost all drugs increase the sedative effect of midazolam (alcohol, opioids, erythromycin, antidepressants, antihistamines, antipsychotics, recreational drugs)

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58
Q

What is ASA Classification?

A

American society of anaesthesiologist scale used to work out the risk of treatment by grading the patient

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59
Q

ASA I

A

Normal healthy patient
Non smoker
Minimal alcohol

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60
Q

ASA II

A

Mild systemic disease
E.g. pregnant, well controlled asthma or epilepsy, slightly raised BP

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61
Q

Ideal blood pressure

A

Between 90/60 and 120/80 mmHg

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62
Q

ASA III

A

Severe systemic disease, limits activity but not incapacitating
e.g. Insulin dependent diabetes mellitus, >6 months post MI or CVA, stable angina

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63
Q

ASA IV

A

Severe systemic disease, constant threat to life
Severe COPD
<3 months post MI, stenting, CVA

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64
Q

ASA V

A

Moribund, not expected to live >24 hours

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65
Q

ASA VI

A

Patient who is brain dead for organ donation

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66
Q

Where should ASA I sedation tx be done?

A

Primary care

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67
Q

Where can ASA II sedation treatment be done?

A

Primary care

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68
Q

Where should ASA III sedation treatment be done?

A

Secondary care

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69
Q

Where can ASA IV sedation treatment be done?

A

Must be done in secondary care

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70
Q

Why is respiratory disease relevant to sedation?

A

Almost all sedative agents will cause respiratory depression, so it important to know if a patient has sever asthma or other respiratory disease

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71
Q

Categories of psychiatric disease

A

Neurosis (anxiety, depression)
Psychosis (e.g. schizophrenia)

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72
Q

There are many absolute contra-indicative drugs for sedation
True or fasle

A

False
Few absolute contraindications but many interactions

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73
Q

Pharmacodynamic drug reactions

A

Interaction between drugs which have similar or antagonistic effects or side effects
eg. antidepressants cause respiratory depression, as do BZDs

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74
Q

Pharmacokinetic drug interaction

A

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

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75
Q

Which type of drug interaction is most likely to affect sedation?

A

Pharmacodynamic

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76
Q

What should be done in the general examination of a patient at sedation assessment?

A

Examine for signs of anxiety
Vital signs
- HR
- BP
- oxygen saturation
Weight and BMI

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77
Q

Which vital signs must be recorded at sedation assessment?

A

HR
BP
O2 saturation

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78
Q

Underweight BMI

A

<18.5

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79
Q

Healthy weight BMI

A

18.5-24.9

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80
Q

Obese BMI

A

30+

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81
Q

Properties of the ideal IV sedation agent

A

Anxiolysis
Sedation
Non irritant
No adverse side effects
Easy to administer
Quick onset
Quick recovery
Low cost
Amnesia

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82
Q

How do benzodiazepines work?

A

By acting on receptors in the central nervous system to enhance the effect of GABA, prolonging the time for receptor repolarisation and by mimicking the effects if glycine on receptors

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83
Q

What is GABA?

A

Gamma amino butyric acid, inhibitory neurotransmitter found in the cerebral cortex, motor circuits and CNS

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84
Q

What is glycine?

A

Inhibitory neurotransmitter (similar to GABA) found in the brainstem and spinal cord

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85
Q

What part of the benzodiamine structure allows them to attach to receptors in the CNS?

A

Benzene ring

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86
Q

What drug is usually used for IV sedation and what class is this?

A

Midazolam
Benzodiamine

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87
Q

Why was sedation introduced in dentistry?

A

As an alternative to GA - GA in dentistry has lead to deaths
GA in the dental chair is now illegal in Scotland, meaning less patients can be treated under GA

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88
Q

Conscious sedation GDC definition

A

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 verbal contact with the patient is maintained throughout the period of sedation. The drugs and techniques used to provide conscious sedation for dental treatment should carry a margin of safety wide enough to render unintended loss of consciousness unlikely

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89
Q

What level of sedation must be maintained in dentistry?

A

Must be such that the patient remains conscious, retains protective reflexes and is able to understand and respond to verbal commands
“deep sedation” in which these criteria are not fulfilled must be regarded as general anaesthesia
(in the case of patients who are unable to respond to verbal contact when fully conscious the normal method of communication with them must be maintained)

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90
Q

Indications for treatment with IV sedation in adult patients

A

Conditions aggravated by stress (hypertension, asthma, epilepsy etc)
Conditions which affect cooperation - Parkinson’s, spasticity disorders, SOME learning difficulties (in some IVS will make it worse as inhibitions will be lowered)
Psychosocial reasons - phobia, gagging, fainting, idiosyncrasy to LA

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91
Q

Phobia

A

An irrational and uncontrollable fear, which is related to a specific object or situation. It is persistent, despite avoidance of the provoking stimulus. It has a direct effect on the patient’s lifestyle

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92
Q

What is meant by transference of dental phobia?

A

Someone else has shared negative experiences at the dentist - usually either parents or friends of children - leading to the child becoming afraid of the dentist

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93
Q

Reasons people can find the dentist scary

A

Fear of criticism
Fear of the dentist’s dress
Lack of communication
Helplessness
Invasion of the body orifice

94
Q

Influences on dental phobia

A

Environment
Surgery appearance
Staff continuity
Age
Stage of development
Socio-economic background

95
Q

Dental indications for sedation

A

Difficult or unpleasant procedures
e.g. surgical extraction of wisdom teeth, orthodontic extractions, implants

96
Q

Advantages for the dentist of sedation

A

Decrease dentist stress
Decrease staff stress
Decrease patient stress
Fewer medical incidents
More productive appointments

97
Q

Disadvantages of sedation

A

Training required - cost and time
Equipment required
Recovery time and after care

98
Q

ASA class 1

A

Normal healthy patient

99
Q

ASA 2

A

A patient with mild systemic disease

100
Q

ASA 3

A

A patient with sever (or poorly controlled) systemic disease

101
Q

ASA 4

A

A patient with severe systemic disease that is a constant threat to life

102
Q

Which ASA groups can an IV sedation trained dentist treat?

A

ASA 1 or 2
(anaesthetist required for any other group)

103
Q

Social contraindications for sedation

A

Unwilling patients
Uncooperative
Unaccompanied (IV)
Children under 12 (IV)
Very old patients

104
Q

Dental contraindications for sedation

A

Procedure too difficult for LA
Procedure too long
Spreading infection - airway threatening, limits LA
Procedure too traumatic

105
Q

Medical contraindications to sedation

A

Severe or uncontrolled systemic disease
Severe mental or physical disabilities - unable to communicate or unable to understand
Severe psychiatric problems
Narcolepsy - must maintain communication
Hypothyroidism
Intracranial pathology - loss of alertness could be result of sedation or pathology

106
Q

Inhalational contraindications for sedation

A

Blocked nasal airway
COPD
Pregnancy

107
Q

Indications for inhalation sedation

A

Anxiety - mild to moderate
Needle phobia
Gagging
Traumatic procedures - extractions, oral surgery
Medical conditions aggravated by stress
Unaccompanied adults requiring sedation

108
Q

Contraindications for inhalation sedation

A

Common cold - nose breathing required
Tonsillar/adenoidal enlargement
Severe COPD
First trimester of pregnancy - unknown how much of a risk this is
Fear of mask/claustrophobia
Patients with limited ability to understand - including small children, minimum age 5-7

109
Q

On completion of inhalation sedation

A

Adult patients may leave unaccompanied at dentist’s discretion
Child patients (<16 years) must be accompanied by a competent adult
Prior to discharge, ask how patient felt procedure went and listen
Patients may feel shivery - reassure pt that this is common and passes quickly

110
Q

What is the success rate for inhalation sedation

A

Published data says 50-90%

111
Q

What determines the likelihood of success of inhalation sedation?

A

Appropriate patient assessment and selection
Differences in different pt populations
Greater success for orthodontic extractions
Poorer in pts with pain

112
Q

Inhalation sedation recovery once treatment carried out

A

Increase O2 10-20% per minute until 100%
Administer 100% O2 for 2-3mins before turning off machine
Remove hood and turn off gas flow
Return patient to upright slowly, give praise and reassurance

113
Q

Why deliver 100% oxygen when finished treating patient under inhalation sedation?

A

To avoid diffusion hypoxia
(a factor which influences the partial pressure of oxygen within the alveolus)
This is a theoretical risk, the equipment always delivers enough O2

114
Q

Where is inhalation sedation normally used?

A

PDS or dental hospital setting (rarely used in practice)

115
Q

Labels top to bottom

A

Oxygen flow meter - measures flow rates of up to 10 L/min (reading taken from equator of ball, +/- 5% accuracy)
Mixture control dial
Flow control knob

116
Q

What is the lowest concentration of oxygen given during inhalation sedation?

A

50%
(there is only 21% O2 in air)

117
Q

What is the oxygen flush button for in inhalation sedation?

A

Emergency use OR to fill reservoir bag

118
Q

What is the reservoir bag in inhalation sedation?

A

Bag 2 or 3 litre (smaller available for children) to emulate patients lungs
The bag should move visibly with every inspiration and expiration and must not collapse
Helps to monitor respiration
Want a level where the bag moves gently in and out

119
Q

What does it mean if the reservoir bag flattens?

A

Not enough gas given

120
Q

What does it mean if reservoir bag looks stuffed full?

A

Too much gas given

121
Q

Ideal respiration rate

A

12-16 breaths per min

122
Q

Why is it important that waste gas is scavenged during IS?

A

So that people in the room are not breathing in nitrous oxide

123
Q

How is rebreathing of expired gases prevented?

A

Non return valve in the expiratory limb

124
Q

Why is size of nasal hood important?

A

To create a seal so that nitrous oxide is not leaking out

125
Q

Safety features of inhalation sedation set up

A

Air entrainment valve
Oxygen flush button
Oxygen monitor
Reservoir bag
Colour coding
Scavenging system
Oxygen and nitrous oxide pressure dials
Pressure reducing valves
One way expiratory valve
Quick fit connection for positive pressure oxygen delivery
Full tank (esp oxygen) kept on the back of machine, replaced if used between pts

126
Q

Advantages of IS

A

Rapid onset (2-3 mins)
Rapid peak action (3-5mins)
Depth altered either way
Flexible duration
Rapid recovery
No injection (for the sedation, LA still required)
Few side effects to pt
Drug not metabolised
Some analgesia (though better for ischaemic than inflammatory pain)
No amnesia

127
Q

Disadvantages of IS

A

Equipment and gases expensive
Space occupying equipment
Not potent - must be a cooperative pt who just needs a little help
Requires ability to breathe through nose
Chronic exposure risk (unlikely)
Staff addiction
Difficult to accurately determine the actual dose (+/- 5% from reading, nasal hood leakage, if pt speaks they will breathe through mouth, crying can affect)

128
Q

Signs of adequate sedation with IS

A
  • Patient relaxed/comfortable
    • Patient awake
    • Reduced blink rate
    • Laryngeal reflexes unaffected
    • Vital signs unaffected
    • Gag reflex reduced
    • Mouth open on request
    • Decreased reaction to painful stimuli
    • Decrease in spontaneous movements
      Verbal contact maintained
129
Q

symptoms of adequate sedation with IS

A
  • Mental and physical relaxation
    • Lessened awareness of pain
    • Paraesthesia - lips, fingers, toes, legs, tongue
    • Lethargy/”a few pints”, “why your mum is less grumpy after a glass of wine”
    • Euphoria
    • Detachment ‘floating feeling’
    • Warmth
    • Altered awareness of passage of time
    • Dreaming
    • Small controllable “fit of the giggles”
130
Q

Signs and symptoms of over sedation with IS

A
  • Mouth closing - repeatedly
    • Spontaneous mouth breathing
    • Nausea/vomiting
    • Irrational and sluggish responses
    • Decrease cooperation
    • Incoherent speech
    • Uncontrolled laughter, tears
    • Patient no longer enjoying the effects
    • Loss of consciousness
131
Q

Pre-op instructions for IS

A
  • Have a light meal before appointment
    • Routine medicines as usual
    • Children accompanied by a competent adult
    • Adults accompanied to first sedation appt, afterwards they may attend alone
    • Do not drink alcohol on the day of appointment
    • Wear sensible clothing
    • Arrange care of children during and after your appointment
    • Plan to remain in clinic for up to 30 minutes after treatment
132
Q

IS technique before introducing nitrous oxide

A
  • Set up the machine
    • Select nasal hood (record size in notes)
    • Connect to hoses
    • Set mixture dial to 100% O2
    • Settle patient in dental chair
    • Reinforce explanations of procedure
    • Set flow to 5-6L per minute
    • Position hood on patient’s nose
    • Encourage nasal breathing
    • Check reservoir bag movements
  • Small movements = check seal and look for mouth breathing +/- decrease the flow
  • Movements too great = increase the flow rate
    • Patient to be comfortable with hood before proceeding - just let them breathe oxygen for about 1 min
133
Q

Technique when introducing nitrous oxide during IS appt

A
  • Ask patient to signal when begin to feel different
    • Reduce O2 by 10%
    • Wait 1 minute and repeat
    • After O2 reaches 80% reduce by 5% per minute
    • Stop titration when patient is ready for treatment
      Continue with semi hypnotic suggestion - feeling dreamy, floaty, relaxed
134
Q

Monitoring of patient during dental treatment under IS

A

If patient over-sedated increase O2 in 5-10% increments until satisfactory sedation.
If under-sedated decrease O2 in 5% increments until satisfactory sedation.

135
Q

Properties of an ideal IV sedation agent

A
  • Anxiolysis (actual goal)
    • Sedation (is actually a side-effect)
    • Non irritant
    • No side effects
    • Easy to administer
    • Quick onset
    • Quick recovery
    • Low cost
    • Amnesia - actually a useful side effect
136
Q

How do benzodiazepines work?

A

Act on receptors in the CNS to enhance the effect of GABA gamma amino butyric acid, prolonging the time for receptor repolarisation
and mimics the effect of the inhibitory neurotransmitter glycine on receptors

137
Q

What are GABA and glycine?

A

Gamma amino butyric acid is an inhibitory neurotransmitter in the CNS, cerebral cortex and motor circuits
Glycine is a similar inhibitory neurotransmitter, which acts in the brainstem and spinal cord

138
Q

How are active benzodiazepines able to bind to receptors?

A

They all have a benzene ring

139
Q

Respiratory effects of sedative agents

A

CNS depression and muscle relaxation
Decreases cerebral response to increase CO2 (primary driver for breathing)
(Synergistic relationship with other CNS depressants and increased respiratory depression in already compromised patients)

140
Q

Cardiovascular effects of sedative agents

A

Decreased BP by muscle relaxation decreasing vascular resistance
Increased heart rate due to baroreceptor reflex compensating for BP fall

141
Q

Drug interactions of benzodiazepines

A

Any other CNS depressant
Erythromycin
Antihistamines
Among others

142
Q

Consideration for those who take diazepam or valium recreationally

A

These are also benzodiazepines, can develop a tolerance
Because of this, less than 2 weeks allowed for diazepam prescriptions

143
Q

Factors making sexual fantasies more common during IV sedation

A

Higher dose
Operator of opposite sex to pt (dependent on sexuality)
One of the reasons that seditionist can never be alone with pt

144
Q

Diazepam as IV sedation drug

A

The first widely used BZD
Insoluble in water so a preparation with propylene glycol must be used, which caused a lot of pain on injection
Long elimination half life
Risk of rebound sedation
0.1-0.2mg/kg
Long recovery
Unpredictable
Far from ideal - now superseded by midazolam

145
Q

Advantages of midazolam as IV sedation drug

A

Painless on injection as it is water soluble at pH <4 and lipid soluble at physiologic pH - allows passing of BBB blood brain barrier
Rapid onset and 2-3x more potent than diazepam
Short elimination half-life - shorter working time but safer
Metabolised in liver and small amount extra hepatic in bowel so slightly less affected by liver disease than some

146
Q

Midazolam elimination half life

A

90-150 minutes

146
Q
A
147
Q

pH of midazolam

A

3.5

148
Q

Midazolam preparation

A

5mg/ml

149
Q

Why has midazolam superseded Diazepam?

A

Painless injection
Quicker onset
Quicker recovery
More reliable

150
Q

Who must be present in the room during IV sedation?

A

Sedation trained operator (or two separate people)
Sedation trained nurse

151
Q

Who must be present in the recovery room?

A

Sedation trained nurse and patient’s chaperone

152
Q

What type of cannula used for IV sedation and why must it stay in the arm?

A

In-dwelling cannula
It might be needed for a medical emergency
More secure than alternatives and made of Teflon which rarely clots/blocks
Comes in a range of sizes

153
Q

Why is a butterfly cannula not recommended for IV sedation, and what could it be used for?

A

Metal part in the patients hand clots and obstructs very easily and it is easily dislodged
Best use - when taking blood as it will only be in for a short time

154
Q

Most common cannulation site for IV

A

Dorsum of the hand
Accessible
Superficial and visible
BUT
Poorly tethered vessels tend to move
Affected by peripheral vasoconstriction so may need to warm hand

155
Q

Second choice site for cannulation for IV sedation

A

Antecubital fossa
(less stable and less easily accessed than dorsum of hand)

156
Q

Important structures to avoid in cannulation at antecubital fossa and how?

A

Brachial artery and median nerve
Keep lateral

157
Q

Why are two visits minimum for IV sedation?

A

Must have an assessment visit

158
Q

Safety procedure for IV sedation appointment

A

Pre op pulse and BP taken on the day to check nothing has changed
Escort must stay in the building
Check travel arrangements
Check care responsibilities have been covered
Consent - mandatory at assessment but reconfirm
Ensure high volume aspiration on hand
Monitor - pulse oximeter, non invasive BP every 5-10
Have on hand flumazenil and means of ventilation

159
Q

How much time with useful sedation are you likely to get from IV sedation?

A

30-45min

160
Q

How long do you keep a patient after IV sedation?

A

60 mins after last increment

161
Q

Flumazenil

A

Preparation 500mcg in 5ml
Dose 200mcg then 100mcg increments every 60s until response
Reverses midazolam BUT shorter half life 50 mins so risk of re sedation

162
Q

Delivery of IV sedation

A

Pulse oximeter and BP cuff on - take your pre op measurements and be aware of these during sedation
Cannulate the patient and make sure cannula is properly positioned and stable, use elastoplast/dressing to keep in place.
Then can start drug administration - midazolam
2mg initial bolus
Watch for a full minute
1mg increments at 60 second intervals until suitable level of sedation achieved
Recommended not to give more than 7.5mg, often 5mg is the most that you give

163
Q

End point for IV sedation

A
  • Slowing and slurring of speech
    • Relaxed
    • Delayed response to commands
    • Willingness to accept treatment
    • Verrill’s sign -ptosis - drooping eyelids
    • Eve’s sign - loss of motor coordination - to measure, get pt to shut eyes and reach hands quite wide to each side, then touch their nose with their finger, will often miss nose at end point
164
Q

Average midazolam dose

A

5mg

165
Q

Max Midazolam dose

A

7.5mg

166
Q

Factors affecting midazolam therapeutic dose

A

Sleep
Alcohol
Stress
Drugs

167
Q

Recovery following IV sedation

A
  • Escort can be with pt as the second person at this stage
    • Keep until 60 minutes after last increment (write down times of increments given)
    • Cannula - needs to be removed before leaving
    • Ensure patient can walk unaided
      Escort given post op instructions
168
Q

Respiratory depression management during IV sedation

A

Pulse oximeter will probably show this
Talk, shake, hurt
Head tilt chin lift jaw thrust
Encourage deep breaths
If this does not improve oxygen saturation
- O2 2l/min via nasal cannulae first (tx can continue)
- no improvement 02 5l/min via Hudson mask
If not working - flumazenil

169
Q

Guidance used for conscious sedation

A

SDCEP 2017

170
Q

Key points of GDC definition for conscious sedation

A

Remains conscious
Retains protective reflexes
Understands and responds to verbal commands

171
Q

Paediatric sedation assessment history key points

A

Pain - pts in severe pain are already in heightened state of anxiety
Nature of anxiety - dentistry as a whole or something specific
Dental history - more likely to be anxious if a child is aware of a problem
Medical history - may have been through anxiety provoking medical procedures

172
Q

Paediatric sedation assessment patient factors

A

Child must be on board with the idea or they will not be suitable for IS and hypnotic suggestion
Monitors (like to know details) vs Blunters (do not)
MCDASf 9 no dental anxiety >31 or any 5/5 extreme dental phobia

173
Q

Methods of pain and anxiety management in children

A

Non pharmocological behaviour management - hypnosis, CBT, tell-show-do
LA
Sedation
GA

174
Q

What is NPBM?

A

Non pharmacological behavioural management such as hypnosis, CBT, tell-show-do

175
Q

Children being treated with LA

A

With good behavioural management, most children can manage treatment under LA alone
A useful adjunct is sometimes computer controlled single tooth anaesthesia like the wand

176
Q

What is the wand?

A

Computer controlled single tooth anaesthesia system which delivers LA solution at a slow rate and a low pressure
Because of the design of the system (without a traditional syringe) it can be useful with children who have become afraid of LA injections

177
Q

Methods of paediatric sedation

A

Inhalation
Intravenous
Alternative techniques - oral, transmucosal

178
Q

Inhalation sedation

A

Combination of pharmacology and behaviour management. IS with O2 and N2O is most widely used paediatric dentistry sedation
Excellent safety record
Easily titrated to the individual child’s need
Still necessary to use LA and in combination with behaviour management/hypnotic suggestion

179
Q

Nitrous oxide for sedation

A

Has a sweet odour, is pleasant to inhale and is non irritant
Stored as a liquid in cylinders at about 43.5 bar
Low tissue solubility giving rapid onset and recovery

180
Q

Indications for IS in children

A

Age - child must be amenable to hypnotic suggestion and understand nasal breathing
Anxiety level - mild to moderate, can be helpful for needle phobic
Management of gag reflex
Medical considerations - conditions worsened by stress
Previous positive IS experience
Dental needs - more difficult extractions or tricky procedures

181
Q

Contraindications for IS in children

A

Too young to understand the concept - absolute minimum 4/5
Extreme anxiety (unless it is an older child determined to make it work)
Medical considerations - intellectual impairment meaning that they can’t understand hypnotic suggestion or nose breathing, nasal blockage, claustrophobia/mask phobia, myasthenia gravis
Previous unsuccessful IS
Fear of nasal hood
Procedure at front of mouth - nasal hood can get in the way

182
Q

Why is it important to treatment plan IS carefully?

A

IS is much more likely to be successful if it has been discussed from the beginning of treatment, it is much less likely to be successful if it is brought up as a suggestion when the patient is already struggling with the treatment they are undergoing

183
Q

Consent considerations for IS in children

A

Check that pt and parent understand
- What will happen
- How the child will feel
- Sensations such as tingling, floating
- Reassure that they will be back to normal in 5-10 minutes
- Ensure that they know that they will still need LA
- Written pre and post op instructions

184
Q

Pre op instructions for Paediatric IS

A

Child can eat and drink but should avoid having a heavy meal
Accompanying parent can NOT be in the surgery during IS if pregnant
If the child has a blocked nose, get in touch as they cant have sedation as it won’t work - colds in winter, hayfever in summer

185
Q

Post op instructions for paediatric IS

A

Child needs to be supervised by an adult for the rest of the day
Can still go to school, make teacher aware that they have had sedation
No contact sport or bike riding for the rest of the day

186
Q

Maximum level of IS signs

A

When child reports tingling or starts giggling/becomes over excited

187
Q

Why is it important to avoid moving nitrous oxide dose up and down during sedation?

A

This can make the child feel nauseous

188
Q

Most common IV sedation drug used for children

A

Propofol (more predictable than midazolam)

189
Q

Indications for IV sedation in children

A

Age - usually 12+
Anxiety moderate to severe, general dental phobia or fear of intra-oral injections (not sever needle phobic)
Medical considerations - conditions worsened by anxiety, generalised anxiety, previous positive IV sedation
PDH - previous difficulty, lots of treatment history or non
Dental needs - complex or lots of treatment required

190
Q

Contraindications for IV sedation in children

A

Age <12
Needle phobic, uncomfortable with cannulation
Medical considerations - intellectual impairment, wouldn’t understand what’s going on
If patient really likes to monitor, unsuitable because of amnesic effect, unsuitable for those who can not handle lack of control
Procedure too long

191
Q

Why is general anaesthetic usually required?

A

High volume of treatment need or very young pt

192
Q

What is TCI propofol?

A

Target controlled infusion TCI sedation
Administered by anaesthetist in a low dose for sedation, continuously titrated for the degree of sedation
Useful for very short and very long procedures
Rapid onset and recovery

193
Q

Consent for IV sedation for children

A

Check understanding of patient and parent
Written pre and post op instructions
Child must be accompanied and cared for the rest of the day, taken home in a car or taxi
Nothing strenuous or potentially dangerous for 24h
No alcohol or sedative drugs
Take care over texts and social media

194
Q

Assessment visit for TCI propofol

A

Weight, BP, HR
Given topical anaesthetic cream EMLA to use on hand before coming in to sedation visit

195
Q

Paediatric IV sedation appointment structure

A

BP and HR checked
Sedation delivered
LA given
Tx carried out
Recovery checked - can they walk unaided
Pot op instructions given in writing

196
Q

Alternative sedation (not IS or IV)

A

Oral and transmucosal
Often midazolam
Less controlled
Suitable for minority
Sometimes given so that cannulation can be done
This is an advanced technique in children

197
Q

What is meant by poor oral health related QoL?

A

People missing school or work, not socialising with friends, could be struggling to eat, or could avoid smiling due to embarrassment, which can all be results of dental fear and anxiety

198
Q

What is the cycle of dental fear and anxiety and sedation?

A

Patient who experiences DFA will avoid until they have pain, then attend for treatment and have sedation to get through it, then disappear and avoid the dentist until the next time they have pain, which will result in them having sedation again

199
Q

Is psychological or pharmacological management of DFA more effective?

A

Research shows psychological interventions are more effective

200
Q

How is CBT used in DFA?

A

Can prepare pt to have sedation OR can stand alone as a method of controlling dental anxiety

201
Q

What is the guidance for conscious sedation?

A

SDCEP

202
Q

What is the objective of CBT?

A

Provide psychoeducation and use behavioural modification techniques and cognitive restructuring skills to challenge unhelpful beliefs and behaviours

203
Q

Dental anxiety

A

General type of fear
Occurs without a present triggering stimulus
Emotional response to an unknown danger or perceived threat
Anticipatory due to previous negative experiences

204
Q

Dental fear

A

An intense biological response to immediate danger which is specific
Encourages caution and safety

205
Q

Dental phobia

A

Most common specific phobia (11% UK adults)
Clinical mental disorder
Overwhelming and debilitating fear of an object, place, situation or animal
Interference with daily life

206
Q

Aetiology of dental fear/anxiety/phobia

A

Direct experiences - having had painful tx
Observations - have seen a parent or someone upset in a dental setting
What you are told - friends/family/teachers/media depicting the dentist as something to be afraid of
Personality - some traits are more commonly associated with phobias
Genes - not born with it but might make you more vulnerable

207
Q

Potential triggers to DFA

A
  1. Fear of a specific stimuli
  2. Fear of a medical catastrophe
  3. Generalised dental anxiety
  4. Mistrustful of dental personnel
208
Q

What is trauma?

A

An event of actual or extreme threat of physical or psychological harm which an individual experiences as traumatic, and which causes long lasting effects
- single incident trauma
- complex trauma

209
Q

Why is treating phobic patients more difficult for dentists?

A

Can be stressful
Can need up to 20% more time in the chair
More extensive treatment may be required due to neglect
Can have a number of FTAs

210
Q

Modified dental anxiety scale

A

A structured, validated, self-report anxiety questionnaire
Validated for use age 16+
Score 5-25
>19 or 5/5 on a question = severe anxiety/phobia

211
Q

Structured Assessment of child patients with dental fear and anxiety

A

Modified child dental anxiety scale - faces version MCDASf
A structured, validated, self report anxiety questionnaire
Validated for use age 8-15
Score 9-45
>27 = severe DFA/phobia

212
Q

Why is it important to determine why a patient is anxious before treatment planning?

A

The problem may be fear of feeling out of control, or needle phobia, which could make sedation unsuitable

213
Q

Psychological approaches for DFA

A

CBT
Hypnosis

214
Q

5 factors influencing fear and anxiety in building blocks of fear and anxiety 5 factors model

A

Situation
Thoughts
Moods
Body sensations
Behaviours

215
Q

Emotional component of DFA

A

Anxious
Scared
Shame
Guilt
Anger

216
Q

Physiological component of DFA

A

Increased HR
Dry mouth
Increased perspiration
Butterflies in stomach
Flushed face
Increased muscle tension

217
Q

Cognitive component of DFA

A

Expectation of failure
Catastrophising
Fortune telling
Magnifying (how bad it will be)
Minimising (our ability to cope)

218
Q

Behaviour component of DFA

A

Avoidance
Disruptive behaviour
Increased muscle tension
Safety behaviours - strategies used to help cope

219
Q

What is STOPP for managing DFA?

A

Stop
Take a breath
Observe your surroundings
Put it into perspective
Practice coping mechanisms

220
Q

Two of the main tools to use to alleviate physical reactions to DFA

A

Controlled breathing
Progressive muscle reaction

221
Q

3 steps to break the cycle of DFA thoughts

A

Step 1 - catch the thoughts
Step 2 - challenge the thoughts
Step 3 - find alternative thoughts

222
Q

Quiet breathing

A

Contraction of respiratory muscles, mostly the diaphragm
Increases thoracic breathing
In turn thoracic pressure reduced
Air pushed in along the pressure gradient - inspiration
Expiration is passive

223
Q

What is used in more forceful breathing that is not used in quiet breathing?

A

Intercostal and accessory muscles

224
Q

What is the difference between quiet breathing and forceful breathing?

A

In forceful breathing intercostal and accessory muscles are used

225
Q

What drives airflow in breathing?

A

Pressure gradients
When atmospheric pressure>alveolar pressure - inspiration
When alveolar>atmospheric - expiration

226
Q

Effect of posture on breathing

A

Contraction of diaphragm drives respiration
Movement of diaphragm can be complicated by abdominal cavity contents, its movement is facilitated in sitting position as compared with lying down

227
Q

Obstructive pulmonary diseases

A

Asthma
Emphysema
Bronchitis

228
Q

Conduction zone of airway

A

No gas exchange, anatomical dead space
Trachea, bronchi and bronchioles

229
Q

Respiratory zone

A

Region of gas exchange
Respiratory bronchioles, alveolar ducts and alveolar sacs

230
Q

How do gases move over alveolar wall?

A

Diffusion

231
Q
A

BDS4 (18 decks)

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