CDS Sedation Flashcards
Special care dentistry
Dentistry for those with a disability or activity restriction that directly or indirectly affects their oral health
Problems in providing dental treatment in special care
Communication
Anxiety
Moving target
Perception of reality
Previous experience
Possible reasons for involuntary movements
Parkinson’s
Learning difficulties
Muscular dystrophy
Cerebral palsy
Multiple sclerosis
Huntingdon’s Chorea
Head injury
Why does Midazolam help with involuntary movements?
It is a muscle relaxant
Congenital vs acquired learning difficulties
Congenital - syndromic or non-syndromic
Acquired - trauma, infection, cerebral vascular accident, Alzheimer’s
Assessment of pts with involuntary movements
Mental and physical status
Anxiety
Pain experience
Assessment of pt with learning difficulties
Is behaviour management possible?
Is pharmalogical management needed?
PT understanding?
Pt pain experience?
What to do if a patient is competent to consent but can’t write?
Verbal consent, documented in notes
Adults with incapacity certificate
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
Conscious sedation techniques
Inhalation
Intravenous
Oral
Transmucosal - rectal, intranasal, sublingual
Choice of sedation depends on
Patient cooperation
Degree of anxiety
Dentistry required
Skills of the dental team
Patient’s previous experience
Facilities available
Anaesthetist required?
Advantages of inhalation sedation
Useful for anxiety relief
Rapid recovery
Flexible duration
Disadvantages of inhalation sedation
Keeping nasal hood in place
Less muscle relaxation
Coordination of nasal breathing when mouth open - cooperation important, understand behavioural management
Advantages of IV sedation
Good sedation achieved
Less cooperation needed
Muscle relaxation
Disadvantages of IV sedation
Baseline readings
IV cannulation required
Assessing sedation level
Behaviour during recovery
Efficacy swallowing
IV sedation types
Midazolam
Propofol
Multiple agent
Safety considerations of IV sedation
Swallowing
Airway
Liver
Medical interactions
ASA - american society of anaesthesiologists assessment of health
Advantages of oral/transmucosal sedation
Avoids cannulation
Can make induction more pleasant
Better cooperation
Better future behaviour
Disadvantages of oral/transmucosal sedation
Baseline readings
Bitter taste/stinging
Lag time
Untitreable
Difficulty monitoring level of sedation
Behaviour in recovery
Possible outcomes from sedation
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
Treatment planning for sedation patients
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
Considerations for GA vs sedation
Safety - controlled airway with GA, difficult intubation
Cooperation
Waiting lists and access to services
Pain
Medical history
(Still a need for GA)
Dangerous sedation
Bolus sedation
Untrained seditionists
Incorrect doses due to wrong labels or incorrect concentration
Reliance on flumazenil
Types of sedation used in dentistry
Inhalation - nitrous oxide
Intravenous - usually midazolam (type of benzodiazepine) cannula in the hand
Reverse midazolam
Flumazenil
Average dose of midazolam used in dentistry
5-6mg
What can be used before an appt to help anxious patients get there?
Pre med diazepam can be used
5mg tablet
Conscious sedation
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
Complications of cannulation
Venospasm
Extravascular injection
Intraarterial injection
Haematoma
Fainting
Complications of drug administration
Hyper responders
Hypo responders
Paradoxical reactions
Oversedation
Allergic reactions
Venospasm
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
Extravascular injection
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
Intra-arteiral injection
(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
Haematoma
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
Fainting during IV sedation
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
Hyper responders to IV sedation
Deep sedation with minimal dose, 1-2mg midazolam, often elderly, titrate slowly in 1mg increments
Hypo responders to IV sedation
Little sedative effect with large dose
Check cannulation
May be due to tolerance - BZD users, cross tolerance
Idiopathic
Threshold to abandon is unknown
Paradoxical reactions to IV sedation
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
Oversedation with IV
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
How to manage respiratory depression during IV sedation
Check oximeter
Stimulate pt
Ask to breathe
Supplemental oxygen nasal cannulae 2L per minute
Reverse with flumazenil
Half life of midazolam
Elimination half life of midazolam is 1-2 hours so can be in system for 12 hours
Oversedation during inhalation sedation
Turn it off, if pt comes round decrease by 5-10% before turning back on
Do not remove nose piece
Management of patient panic during inhalation sedation
Reassure
If pt can not cope abort
Signs of nitrous oxide overdose
Pt discomfort
Lack of pt cooperation
Mouth breathing
Giggling
Nausea
Vomiting
Loss of consciousness
Concentration of Nitrous oxide given in inhalation sedation
70%
30% oxygen
How can oversedation happen?
Initially by misjudging the dose
Later - traumatic procedure over, mouth breathing ceases
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 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
Guidelines for sedation
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
GDP role in sedation
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
What is sedation assessment for?
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
Essential considerations for assessment for sedation
Essential prerequisite
Separate visit
Physiology, pathology and psychology
Good clear communication
Pleasant surroundings and staff
Promptness
Assessment appointment includes
History (social, dental, medical)
Examination (general, oral, vital signs)
Treatment plan
Consent
Information for patient and escort
Social history for sedation assessment
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
Dental history for sedation assessment
Referral source
Previous bad experience
Previous sedation/GA and any problems
Symptoms - acute or chronic
Proposed procedure
How long is the optimal working time under IV sedation?
45 minutes
Medical history for sedation assessment
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
Why is a medical history so important for sedation assessment?
Drug interactions
Almost all drugs increase the sedative effect of midazolam (alcohol, opioids, erythromycin, antidepressants, antihistamines, antipsychotics, recreational drugs)
What is ASA Classification?
American society of anaesthesiologist scale used to work out the risk of treatment by grading the patient
ASA I
Normal healthy patient
Non smoker
Minimal alcohol
ASA II
Mild systemic disease
E.g. pregnant, well controlled asthma or epilepsy, slightly raised BP
Ideal blood pressure
Between 90/60 and 120/80 mmHg
ASA III
Severe systemic disease, limits activity but not incapacitating
e.g. Insulin dependent diabetes mellitus, >6 months post MI or CVA, stable angina
ASA IV
Severe systemic disease, constant threat to life
Severe COPD
<3 months post MI, stenting, CVA
ASA V
Moribund, not expected to live >24 hours
ASA VI
Patient who is brain dead for organ donation
Where should ASA I sedation tx be done?
Primary care
Where can ASA II sedation treatment be done?
Primary care
Where should ASA III sedation treatment be done?
Secondary care
Where can ASA IV sedation treatment be done?
Must be done in secondary care
Why is respiratory disease relevant to sedation?
Almost all sedative agents will cause respiratory depression, so it important to know if a patient has sever asthma or other respiratory disease
Categories of psychiatric disease
Neurosis (anxiety, depression)
Psychosis (e.g. schizophrenia)
There are many absolute contra-indicative drugs for sedation
True or fasle
False
Few absolute contraindications but many interactions
Pharmacodynamic drug reactions
Interaction between drugs which have similar or antagonistic effects or side effects
eg. antidepressants cause respiratory depression, as do BZDs
Pharmacokinetic drug interaction
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
Which type of drug interaction is most likely to affect sedation?
Pharmacodynamic
What should be done in the general examination of a patient at sedation assessment?
Examine for signs of anxiety
Vital signs
- HR
- BP
- oxygen saturation
Weight and BMI
Which vital signs must be recorded at sedation assessment?
HR
BP
O2 saturation
Underweight BMI
<18.5
Healthy weight BMI
18.5-24.9
Obese BMI
30+
Properties of the ideal IV sedation agent
Anxiolysis
Sedation
Non irritant
No adverse side effects
Easy to administer
Quick onset
Quick recovery
Low cost
Amnesia
How do benzodiazepines work?
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
What is GABA?
Gamma amino butyric acid, inhibitory neurotransmitter found in the cerebral cortex, motor circuits and CNS
What is glycine?
Inhibitory neurotransmitter (similar to GABA) found in the brainstem and spinal cord
What part of the benzodiamine structure allows them to attach to receptors in the CNS?
Benzene ring
What drug is usually used for IV sedation and what class is this?
Midazolam
Benzodiamine
Why was sedation introduced in dentistry?
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
Conscious sedation GDC definition
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
What level of sedation must be maintained in dentistry?
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)
Indications for treatment with IV sedation in adult patients
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
Phobia
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
What is meant by transference of dental phobia?
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
Reasons people can find the dentist scary
Fear of criticism
Fear of the dentist’s dress
Lack of communication
Helplessness
Invasion of the body orifice
Influences on dental phobia
Environment
Surgery appearance
Staff continuity
Age
Stage of development
Socio-economic background
Dental indications for sedation
Difficult or unpleasant procedures
e.g. surgical extraction of wisdom teeth, orthodontic extractions, implants
Advantages for the dentist of sedation
Decrease dentist stress
Decrease staff stress
Decrease patient stress
Fewer medical incidents
More productive appointments
Disadvantages of sedation
Training required - cost and time
Equipment required
Recovery time and after care
ASA class 1
Normal healthy patient
ASA 2
A patient with mild systemic disease
ASA 3
A patient with sever (or poorly controlled) systemic disease
ASA 4
A patient with severe systemic disease that is a constant threat to life
Which ASA groups can an IV sedation trained dentist treat?
ASA 1 or 2
(anaesthetist required for any other group)
Social contraindications for sedation
Unwilling patients
Uncooperative
Unaccompanied (IV)
Children under 12 (IV)
Very old patients
Dental contraindications for sedation
Procedure too difficult for LA
Procedure too long
Spreading infection - airway threatening, limits LA
Procedure too traumatic
Medical contraindications to sedation
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
Inhalational contraindications for sedation
Blocked nasal airway
COPD
Pregnancy
Indications for inhalation sedation
Anxiety - mild to moderate
Needle phobia
Gagging
Traumatic procedures - extractions, oral surgery
Medical conditions aggravated by stress
Unaccompanied adults requiring sedation
Contraindications for inhalation sedation
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
On completion of inhalation sedation
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
What is the success rate for inhalation sedation
Published data says 50-90%
What determines the likelihood of success of inhalation sedation?
Appropriate patient assessment and selection
Differences in different pt populations
Greater success for orthodontic extractions
Poorer in pts with pain
Inhalation sedation recovery once treatment carried out
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
Why deliver 100% oxygen when finished treating patient under inhalation sedation?
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
Where is inhalation sedation normally used?
PDS or dental hospital setting (rarely used in practice)
Labels top to bottom
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
What is the lowest concentration of oxygen given during inhalation sedation?
50%
(there is only 21% O2 in air)
What is the oxygen flush button for in inhalation sedation?
Emergency use OR to fill reservoir bag
What is the reservoir bag in inhalation sedation?
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
What does it mean if the reservoir bag flattens?
Not enough gas given
What does it mean if reservoir bag looks stuffed full?
Too much gas given
Ideal respiration rate
12-16 breaths per min
Why is it important that waste gas is scavenged during IS?
So that people in the room are not breathing in nitrous oxide
How is rebreathing of expired gases prevented?
Non return valve in the expiratory limb
Why is size of nasal hood important?
To create a seal so that nitrous oxide is not leaking out
Safety features of inhalation sedation set up
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
Advantages of IS
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
Disadvantages of IS
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)
Signs of adequate sedation with IS
- 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
symptoms of adequate sedation with IS
- 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”
Signs and symptoms of over sedation with IS
- 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
Pre-op instructions for IS
- 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
IS technique before introducing nitrous oxide
- 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
Technique when introducing nitrous oxide during IS appt
- 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
Monitoring of patient during dental treatment under IS
If patient over-sedated increase O2 in 5-10% increments until satisfactory sedation.
If under-sedated decrease O2 in 5% increments until satisfactory sedation.
Properties of an ideal IV sedation agent
- 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
How do benzodiazepines work?
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
What are GABA and glycine?
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
How are active benzodiazepines able to bind to receptors?
They all have a benzene ring
Respiratory effects of sedative agents
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)
Cardiovascular effects of sedative agents
Decreased BP by muscle relaxation decreasing vascular resistance
Increased heart rate due to baroreceptor reflex compensating for BP fall
Drug interactions of benzodiazepines
Any other CNS depressant
Erythromycin
Antihistamines
Among others
Consideration for those who take diazepam or valium recreationally
These are also benzodiazepines, can develop a tolerance
Because of this, less than 2 weeks allowed for diazepam prescriptions
Factors making sexual fantasies more common during IV sedation
Higher dose
Operator of opposite sex to pt (dependent on sexuality)
One of the reasons that seditionist can never be alone with pt
Diazepam as IV sedation drug
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
Advantages of midazolam as IV sedation drug
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
Midazolam elimination half life
90-150 minutes
pH of midazolam
3.5
Midazolam preparation
5mg/ml
Why has midazolam superseded Diazepam?
Painless injection
Quicker onset
Quicker recovery
More reliable
Who must be present in the room during IV sedation?
Sedation trained operator (or two separate people)
Sedation trained nurse
Who must be present in the recovery room?
Sedation trained nurse and patient’s chaperone
What type of cannula used for IV sedation and why must it stay in the arm?
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
Why is a butterfly cannula not recommended for IV sedation, and what could it be used for?
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
Most common cannulation site for IV
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
Second choice site for cannulation for IV sedation
Antecubital fossa
(less stable and less easily accessed than dorsum of hand)
Important structures to avoid in cannulation at antecubital fossa and how?
Brachial artery and median nerve
Keep lateral
Why are two visits minimum for IV sedation?
Must have an assessment visit
Safety procedure for IV sedation appointment
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
How much time with useful sedation are you likely to get from IV sedation?
30-45min
How long do you keep a patient after IV sedation?
60 mins after last increment
Flumazenil
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
Delivery of IV sedation
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
End point for IV sedation
- 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
Average midazolam dose
5mg
Max Midazolam dose
7.5mg
Factors affecting midazolam therapeutic dose
Sleep
Alcohol
Stress
Drugs
Recovery following IV sedation
- 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
Respiratory depression management during IV sedation
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
Guidance used for conscious sedation
SDCEP 2017
Key points of GDC definition for conscious sedation
Remains conscious
Retains protective reflexes
Understands and responds to verbal commands
Paediatric sedation assessment history key points
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
Paediatric sedation assessment patient factors
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
Methods of pain and anxiety management in children
Non pharmocological behaviour management - hypnosis, CBT, tell-show-do
LA
Sedation
GA
What is NPBM?
Non pharmacological behavioural management such as hypnosis, CBT, tell-show-do
Children being treated with LA
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
What is the wand?
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
Methods of paediatric sedation
Inhalation
Intravenous
Alternative techniques - oral, transmucosal
Inhalation sedation
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
Nitrous oxide for sedation
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
Indications for IS in children
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
Contraindications for IS in children
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
Why is it important to treatment plan IS carefully?
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
Consent considerations for IS in children
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
Pre op instructions for Paediatric IS
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
Post op instructions for paediatric IS
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
Maximum level of IS signs
When child reports tingling or starts giggling/becomes over excited
Why is it important to avoid moving nitrous oxide dose up and down during sedation?
This can make the child feel nauseous
Most common IV sedation drug used for children
Propofol (more predictable than midazolam)
Indications for IV sedation in children
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
Contraindications for IV sedation in children
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
Why is general anaesthetic usually required?
High volume of treatment need or very young pt
What is TCI propofol?
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
Consent for IV sedation for children
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
Assessment visit for TCI propofol
Weight, BP, HR
Given topical anaesthetic cream EMLA to use on hand before coming in to sedation visit
Paediatric IV sedation appointment structure
BP and HR checked
Sedation delivered
LA given
Tx carried out
Recovery checked - can they walk unaided
Pot op instructions given in writing
Alternative sedation (not IS or IV)
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
What is meant by poor oral health related QoL?
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
What is the cycle of dental fear and anxiety and sedation?
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
Is psychological or pharmacological management of DFA more effective?
Research shows psychological interventions are more effective
How is CBT used in DFA?
Can prepare pt to have sedation OR can stand alone as a method of controlling dental anxiety
What is the guidance for conscious sedation?
SDCEP
What is the objective of CBT?
Provide psychoeducation and use behavioural modification techniques and cognitive restructuring skills to challenge unhelpful beliefs and behaviours
Dental anxiety
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
Dental fear
An intense biological response to immediate danger which is specific
Encourages caution and safety
Dental phobia
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
Aetiology of dental fear/anxiety/phobia
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
Potential triggers to DFA
- Fear of a specific stimuli
- Fear of a medical catastrophe
- Generalised dental anxiety
- Mistrustful of dental personnel
What is trauma?
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
Why is treating phobic patients more difficult for dentists?
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
Modified dental anxiety scale
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
Structured Assessment of child patients with dental fear and anxiety
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
Why is it important to determine why a patient is anxious before treatment planning?
The problem may be fear of feeling out of control, or needle phobia, which could make sedation unsuitable
Psychological approaches for DFA
CBT
Hypnosis
5 factors influencing fear and anxiety in building blocks of fear and anxiety 5 factors model
Situation
Thoughts
Moods
Body sensations
Behaviours
Emotional component of DFA
Anxious
Scared
Shame
Guilt
Anger
Physiological component of DFA
Increased HR
Dry mouth
Increased perspiration
Butterflies in stomach
Flushed face
Increased muscle tension
Cognitive component of DFA
Expectation of failure
Catastrophising
Fortune telling
Magnifying (how bad it will be)
Minimising (our ability to cope)
Behaviour component of DFA
Avoidance
Disruptive behaviour
Increased muscle tension
Safety behaviours - strategies used to help cope
What is STOPP for managing DFA?
Stop
Take a breath
Observe your surroundings
Put it into perspective
Practice coping mechanisms
Two of the main tools to use to alleviate physical reactions to DFA
Controlled breathing
Progressive muscle reaction
3 steps to break the cycle of DFA thoughts
Step 1 - catch the thoughts
Step 2 - challenge the thoughts
Step 3 - find alternative thoughts
Quiet breathing
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
What is used in more forceful breathing that is not used in quiet breathing?
Intercostal and accessory muscles
What is the difference between quiet breathing and forceful breathing?
In forceful breathing intercostal and accessory muscles are used
What drives airflow in breathing?
Pressure gradients
When atmospheric pressure>alveolar pressure - inspiration
When alveolar>atmospheric - expiration
Effect of posture on breathing
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
Obstructive pulmonary diseases
Asthma
Emphysema
Bronchitis
Conduction zone of airway
No gas exchange, anatomical dead space
Trachea, bronchi and bronchioles
Respiratory zone
Region of gas exchange
Respiratory bronchioles, alveolar ducts and alveolar sacs
How do gases move over alveolar wall?
Diffusion
