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BDS4 Sedation Symposium > Complications of Sedation > Flashcards

Complications of Sedation Flashcards

1
Q

What were the adverse findings of the Rapid Response report?

A

Bolus sedation still used

Untrained seditionists

Incorrect doses given- incorrect labels/concentration

Reliance on flumazenil

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2
Q

What is the bolus technique?

A

this is where the drug is put in at one time rather than slowly and gradually by titration while checking regularly

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3
Q

What is the only concentration of midazolam used?

A

1mg/1ml

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4
Q

When should flumazenil be used?

A

Used in an emergency to reverse effect of midazolam only
 Should not be used to speed up recovery
 Should not be relied on with practitioners wrongly choosing to over-sedate patient on purpose

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5
Q

What is the ultimate complication of sedation?

A

Death
 Extremely rare
 Would be due abuse or excessive levels/incorrect doses of drug given

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6
Q

What are the complications of cannulation in IV sedation?

A

Venospasm

Extravascular injection

Intra-arterial injection

Haematoma

Fainting

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7
Q

What is venospasm? (disappearing vein syndrome)

A

Veins collapse at attempted venepuncture (Associated with poorly visible veins)
-> May be accompanied by burning

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8
Q

How is venospasm prevented?

A

Using tourniquet/vein tapping to help dilate vein

Gravity

Warm water/gloves

Quicker puncture

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9
Q

What occurs in an extra-vascular injection?

A

Active drug placed into interstitial space
-> Pain/swelling
-> can result in delayed absorption

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10
Q

How is EVI prevented?

A

Good cannulation

Test dose of saline (flush)

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11
Q

How is EVI treated?

A

Remove cannula

Apply pressure

Reassure

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12
Q

Which artery is most commonly affected by intra-arterial injection?

A

Brachial artery

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13
Q

What are the signs of an IA injection?

A

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 (as artery could constrict and blood supply could be stopped)

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14
Q

How can IA injections be prevented?

A

 Always stay superficial
 Artery walls are thicker- puncture is thicker
 Prevent by going lateral to bicep tendon
 Palpate to check if vessel has pulse (if positive it is not a vein)

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15
Q

How is an IA injection treated?

A

Monitor for loss of pulse- Cold/Discolouration

Leave cannula in situ for 5 mins post drug

No problems – remove

Symptomatic- leave and refer to hospital (procaine 1%)

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16
Q

What can happen if diazepam is giving intra-arterially?

A

Necrosis

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17
Q

What is a haematoma?

A

Extravasation of blood into soft tissues (bruising)
-> Due to damage to vein walls

18
Q

How are haematomas prevented?

A

Good cannulation technique- Avoid multiple holes in vein wall

Pressure on removal of cannula/post operatively
(Operator not patient)

Care with the elderly

19
Q

How are haematomas treated?

A

Time, Rest, Reassurance
-> If severe- ice pack (initially), moist heat (20mins at a time)
-> Consider heparin containing gel

20
Q

What are the main causes of fainting during venipuncture?

A

Being starved

Anxiety toward needles

21
Q

How is fainting prevented?

A

Don’t starve patients

Topical skin anaesthesia

IS First- to relax patient

Position of patient- supine (allows legs to be raised)

22
Q

What are the complications of drug administration in IV sedation?

A

Hyper-responders

Hypo-responders

Parodoxical reactions

Oversedation

Allergic reactions

23
Q

What are the features of hyper-responders?

A

Deep sedation with minimal dose
-> 1-2mg midazolam

24
Q

How can effect in hyper-responders be managed?

A

Care with titration
-> 1mg increments
-> Slow titration in elderly

25
Q

What is the cause of hyporesponse to IV sedation?

A

 Cannula in incorrect place- flush it again?
 Patient may have cocaine/benzo habits (cross tolerance)

26
Q

What is the max dose given to hypo-responder?

A

10mg then stop if not working

27
Q

What are paradoxical reactions?

A

Patient does not sedate as expected:
 Patient becomes more hyper instead of more sedate
 Large reactions (screams) to stimuli such as high speed- check it is numbed properly
-> more common in immature teenagers

28
Q

What should never be done in event of paradoxical reaction to IV sedation?

A

Add more sedative

-> find another management technique instead

29
Q

What is over-sedation and its features?

A

 Lose responsiveness
 Respiratory depression- give oxygen and take deep breaths (usually)
 Loss of ability to maintain airway
 Respiratory arrest- BVM

30
Q

How is over sedation managed?

A

Stop procedure

Shake patient/Shout

A B C

If no response to stimulation and support
-> Reverse with flumazenil 200mcg then 100mcg increments at minute intervals (Watch for 1- 4 hours)

31
Q

How is respiratory depression managed?

A

Check the oximeter
-> If low 90s: Stimulate patient- Ask to breathe deeply
-> If below 90- Supplemental oxygen via Nasal cannulae (2 litres per minute)
->Reverse with flumazenil

32
Q

How is loss of airway control/respiratory arrest managed?

A

Stimulate the patient / assess consciousness

Maintain / clear airway

Ventilate the patient

Reverse sedation

Consider other medical incident

33
Q

What is done if there is an allergic reaction in IV sedation?

A

More likely to be to latex/elastoplast than sedative

-> do not use flumazenil to reverse (doubling up on benzos which patient may have allergy to)
-> manage as if patient not sedated- IM adrenaline and ABC

34
Q

How are dentists/patients protected from sexual fantasy disclosure in IV sedation?

A

Having a chaperone present at all times

35
Q

What are the complications of IS sedation?

A

Oversedation

Patient panics

36
Q

What is the feature of IS machines which prevent hypoxia in the patient?

A

Max percentage of NO in mix is 70%

37
Q

What are the causes of over sedation in IS

A

Misjudging dose

Traumatic part of procedure finished- patient relaxes but dose is not reduced

Mouth breathing- patient receives no effect due to this, then starts to breathe properly through nose and becomes overstated

38
Q

What are the signs and symptoms of Nitrous Oxide overdose?

A

Patient discomfort
Lack of co-operation
Mouthbreathing
Giggling
Nausea
Vomiting
Loss of consciousness

39
Q

How is over sedation in IS treated?

A

Decrease N2O concentration by 5-10%
Reassure
Don’t remove nosepiece (Diffusion hypoxia)- change to 100% oxygen

40
Q

What is diffusion hypoxia and how is it prevented?

A

Diffusion Hypoxia- NO in lungs and bloodstream wants to rush out lungs and tissues into atmosphere (much smaller concentration than what patient is breathing)
-> When turning off keep oxygen on for 3-5mins

41
Q

Why may a patient panic during IS?

A

Only light sedation- may not be enough for their anxiety level
-> reassure and remind them to keep breathing (if they cannot cope-abort)

42
Q

What are the complications of oral and transmucosal sedation?

A

Same as IV

-> manage in the same way
-> if under-sedated top up with IV

BDS4 Sedation Symposium (8 decks)

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