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BDS4 CDS Sedation Symposium > Complications of Sedation > Flashcards

Complications of Sedation Flashcards

1
Q

concentration of midazolam used for IV sedation

A

1mg/1ml midazolam concentration

used due to National Pt Safety Agency report into reducing risk of midazolam overdose injections

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2
Q

2 categories of complication for IV sedation

A

complications during cannulation

complications during drug adminstration

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3
Q

5 complications during cannulation

A
  • Venospasm
  • Extravascular injection
  • Intraarterial injection
  • Haematoma
  • Fainting
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4
Q

5 complications during drug administration

A
  • Hyper-responders
  • Hypo-responders
  • Parodoxical reactions
  • Oversedation
  • Allergic reactions
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5
Q

what is venospasm

A

Disappearing vein syndrome

  • Veins collapse at attempted venepuncture

May be accompanied by burning

Associated with poorly visible veins

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6
Q

management of venospasm

A
  • Time dilating vein
    • Tourniquet on and tap vein
    • Worse with repeated attempts
  • Efficient technique (smooth)
    • Slow skin puncture makes worse
  • Warm water / gloves in winter
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7
Q

what is extravascular injection

A

active drug placed into interstital space

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8
Q

dx for extravascular injection

A

pain

swelling

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9
Q

potential problem due to extravascular IV injection

A

delayed absorption

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10
Q

2 prevention strategies of extravascular IV injection

A
  • Good cannulation
  • Test dose of saline
    • Flush before
    • If get pain/swelling – reposition
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11
Q

3 tx for extravascular IV injection

A
  • Remove cannula
  • Apply pressure
  • Reassure
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12
Q

what is intra-arterial injection when trying to do IV sedation

A
  • Cannula into brachial artery
    • Not superficial, unlike veins
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13
Q

dx intra-arterial injection

A
  • Pain on venepuncture
  • Red blood in cannula (oxygenated)
  • Difficult to prevent leaks (under pressure too so will bubble)
  • Pain radiating distally from site of cannulation
  • Loss of colour or warmth to limb / weakening pulse
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14
Q

2 prevention strategies for intra-arterial injection

A
  • Avoid anatomically prone sites- ACF Medial to biceps tendon (lateral to tendon)
  • Palpate before attack – pulse? Not vein
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15
Q

3 management strategies for intra-arterial injections

A
  • Take cannula out and Apply pressure for 5mins, stop bleeding - OK
  • Check for loss of pulse
    • Cold
    • Discolouration
  • Leave cannula in situ for 5 mins post drug (notice after giving drug)
    • No problems – remove
    • Symptomatic leave & refer to hopspital (procaine 1%)
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16
Q

what is haematoma due to IV sedation

A
  • Extravasation of blood into soft tissues
  • Due to damage to vein walls
  • At venepuncture
    • Poor technique
  • Removal of cannula
    • Failure to apply pressure
    • Care with elderly patients
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17
Q

3 ways to prevent haematoma during IV sedation

A
  • Good cannulation technique
    • Avoid multiple holes in vein wall
  • Pressure post operatively
    • Operator not pt
  • Care with elderly
18
Q

tx strategies for haematoma

A

Time
Rest
Reassurance

If severe

  • Initial ice pack
  • Moist heat 20mins in hour after 24hours

Consider heparin containing gel

19
Q

how can fainting occur during IV sedation (venopuncture)

A
  • Anxiety related to venepuncture
  • Worse if starved
20
Q

4 prevention strategies for fainting during venopuncture

A
  • Don’t starve patients
  • Topical skin anaesthesia
  • RA First – easier to get legs up
  • Position of patient
21
Q

what are hyper-responders to IV sedation

A
  • Deep sedation with minimal dose
    • 1-2mg midazolam
22
Q

prevention of hyper-responders to IV sedation

A

care with titration

1mg increments

slow titration in elderly esp

23
Q

hypo-responders to IV sedation

A

little sedative effect with large doses

24
Q

management of hypo-responders to IV sedation

A
  • Check cannula in vein!!
  • May be due to tolerance
    • BZD induced
    • Cross tolerance
      • E.g. not told you about a drug habit they have (cocaine, benzo habit)
    • Idiopathic

Threshold to abandon??

  • 10mg common in dentistry
  • BNF 7.5mg
25
Q

paradoxical reactions to IV sedation

A

Appear to not sedate normally

Or sedate normally but React extremely to all stimuli

  • Relax when stimuli removed
    • Don’t remember what caused it as midazolam gives amnesia
26
Q

management for paradoxical reactions to IV sedation

A
  • Check for failure of LA
  • DO NOT GO ON ADDING SEDATIVE
  • Find other management technique
  • Watch immature teenagers
    • More likely in younger individuals
27
Q

4 signs of oversedation

A
  • Loss of responsiveness
  • Respiratory depression
  • Loss of ability to maintain airway
  • Respiratory arrest
28
Q

management of oversedation

4 points

A
  • Stop procedure
  • Try to rouse patient
    • Alert – voice, pain or unresponsive
    • Breathing
    • Circulation
  • If no response to stimulation and support (as soon as Alert failed)
    • Reverse with flumazenil 200mg then 100mg increments at minute intervals
    • Watch for 1- 4 hours
      • Flumazenil has shorter half life than midazolam
  • Be more careful next time
29
Q

management of respiratory depression

4 points

A
  • Check the oximeter (not in isolation check with how they look)
  • Stimulate patient
    • Ask to breathe
  • Supplemental oxygen
    • Nasal cannulae 2 litres per minute
  • Reverse with flumazenil
    • If sats drop below 90% and not rising
30
Q

5 management points for loss of airway control and/or respiratory arrest

A
  • Stimulate the patient / assess consciousness
  • Maintain / clear airway
  • Ventilate the patient
  • Reverse sedation
  • Consider other medical incident
31
Q

allergic reactions in IV sedation

A

Rare to sedatives

  • Remember Latex and elastoplast involved

Do not use flumazenil

  • Benzodiazepine like midazolam – could make it worse, if unknown cause

Manage as if not sedated – advantage of IV access

  • Give IM adrenaline
  • A B C check and go for help
32
Q

sexual fantasy due to IV sedation management

A
  • No idea of incidence or aetiology
  • No idea how to prevent

Ensure chaperoned!!!

33
Q

reversal drug for midazolam

A

flumazenil

34
Q

2 complications due to IHS

A

oversedation

pt panics

very safe machine has

  • max dose built in (hypoxic rare as unable to give 100% N2O)
  • cut off
35
Q

oversedations with IHS can occur how

initally

later

A

Initially

  • Misjudge dose

Later

  • Traumatic procedure over
    • E.g. needle phobic, so high level to give LA but that’s happened, pt more relaxed now but still at high level which is too high now so OD
  • Mouth breathing ceases
    • Adjust fit so concentration is higher suddenly
      • Technical problem
36
Q

7 signs and symptoms of N2O overdose

A
  • Patient discomfort
  • Lack of co-operation
  • Mouthbreathing
  • Giggling
  • Nausea
  • Vomiting
  • Loss of consciousness
37
Q

3 points for tx of N2O overdose

A
  • Decrease N2O concentration by 5-10%
  • Reassure
  • Don’t remove nosepiece
    • Diffusion hypoxia
      • If get really panicked can give them 100% O2 through mask but need to keep nosepiece on for 3-5mins
38
Q

pt panics during IHS

why?

A
  • Have you used the correct sedation technique?
    • IHS light sedative, may not be enough for them
39
Q

pt panics during IHS

management

A

Reassurance

If cannot cope with sedation abort

40
Q

complications with oral/transmucosal sedation

A

same as IV sedation

41
Q

undersedation in transmucosal sedation management

A

place cannula and top up with IV

BDS4 CDS Sedation Symposium (8 decks)

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