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FINALS - Pharmacology > Concious Sedation > Flashcards

Concious Sedation Flashcards

1
Q

Describe the mechanism by which quiet inspiration occurs?

A

Diaphragm and inspiratory muscles contract

Increases thoracic volume and therefore pressure decreases

Air is pulled inwards along a pressure gradient

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2
Q

How do you differentiate passive and forced expiration?

A

The involvedment of intercostal and expiratory muscles in forced expiration.

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3
Q

What parts make up vital lung capacity (VLC)?

A

Tidal volume (resting)
Inspiratory reserve volume (IRV)
Expiratory reserve volume (ERV)

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4
Q

What parts make up lung total lung capacity (TLC)?

A

Vital lung capacity (TV, IRV, ERV)
Residual volume (RV)

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5
Q

What is ventilation?

A

The volume of gasses passing between the lungs and air.

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6
Q

What is V:Q ratio?

A

The ratio of ventilation (the amount of gas in the lung) and perfusion (the amount that actually transfers between the alveoli.

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7
Q

What are Bohr shifts?

A

Any conidition or state which alters the natural Hb-O2 dissociation curve.

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8
Q

How is the breathing rhythm generated?

A

An automatic process of muscle contraction generated by respiratory centres in the brainstem.

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9
Q

What is the purpose of the SA node in the heart?

A

A natural pacemaker determining cardiac rhythm.

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10
Q

What is the AV node?

A

Receptor of signal from AV node, directs ventricles to contract via Purkinje system.

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11
Q

Which nervous systems innervate the heart?

A

Parasympathetic via vagus nerve, lowers heart rate and conduction.

Sympathetic via adrenoreceptors, elevates heart rate and cardiac output.

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12
Q

Outline what each of the PQRST waves on an ECG indicate.

A

P-wave: atrial depolarisation
QRS-wave: ventricular depolarisation
T-wave: ventricular repolarisation

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13
Q

How is blood pressure calculated?

A

Cardiac output x total peripheral resistance

CO x TPR

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14
Q

How do you calculate cardiac output?

A

Stroke volume x heart rate
SV x HR

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15
Q

Which factors determine stroke volume?

A

End diastolic volume
Ventricular contractility
Venous return
After load (TPR)

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16
Q

Which veins of the hand are targeted for canulation?

A

Basilic vein
Cephalic vein

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17
Q

What are the advantages of cannulating the hand?

A

Good access
No major anatomical structures nearby

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18
Q

What are the disadvantages of cannulating the hand?

A

Small veins
Susceptible to cold/anxiety
Mobile veins
More painful

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19
Q

What are the advantages to cannulating the cubital fossa?

A

Big well tethered veins
Less painful
Less vasoconstriction

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20
Q

What are the key aspects to consider in a sedation agent?

A

Anxiolysis (sedation)
Ease of administration
Non-irritant
Quick onset
Quick recovery
No side effects
Low cost
+/- amnesia

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21
Q

What is the mechanism by which benzodiazepines induce sedation?

A

Benzodiazepines have benzene ring which attaches to receptors in the CNS

Which mimics the effect of glyciene.

This enhances the effect of GABA, leading to sedation.

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22
Q

What clinical effects do benzodiazepines have?

A

CNS Depression and muscle relaxation

Decrease in cerebral response to CO2

Increase in respiratory depression in already compromised patients

Reduction in BP by reducing TPR

Increase in HR due to baroreceptor compensating for fall in BP

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23
Q

What are the potential side effects of benzodiazepines?

A

Drug interactions with any other CNS depressants, Erythromycin, and antihistamines.

Tolerance and dependence

Sexual fantasies

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24
Q

What were some of the drawbacks of diazepam when it was used as a sedation agent?

A

Long elimination half life
Metabolite half life
Risk of rebound sedation
Long recovery
Unpredictable
Painful upon injection

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25
Q

What advantages does midazolam have over diazepam?

A

Painless
Quicker onset
Quicker recovery
More reliable

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26
Q

What members of staff should be in attendance during sedation of a patient?

A

Operator
Secondary trained sedationist
Runner
Recovery area nurse

All must have appropriate training in sedation and managing emergencies resulting from sedation.

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27
Q

Why is an in-dwelling cannula mandatory for sedation?

A

May be needed to administer medications in an emergency.

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28
Q

Why is a butterfly cannula not advisable for sedation?

A

Higher chance of obstruction
Easily dislodged

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29
Q

What should be established during the assessment appointment for sedation?

A

Pre-op pulse and BP
Travel arrangements
Escort
Written informed consent

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30
Q

What should be monitored during sedation?

A

Sats (Pulse oximeter)
NIBP (Every 5-10 mins)
Allows for intervention before emergency

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31
Q

Why is high volume aspiration recomened for sedation procedures?

A

Patient may have difficulty swalling and breathing for themselves.

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32
Q

What is the purpose of flumazenil?

A

Reversal agent for benzodiazepines.

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33
Q

How should midazolam be given?

A

Through cannula, 2mg bolus to start, then 1mg incrimentally every 60 seconds until desired effect achieved.

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34
Q

What are the signs of someone who has been successfully sedated?

A

Slurring and slowing of speach
Relaxed
Delayed response to commands
Willingness to accept treatment

However verbal communication still maintained.

35
Q

What is the typical maximum recomended dose of midazolam?

A

7.5mg, however most people need a lot less.

36
Q

How long does midazolam sedation typically last for?

A

30-45 minutes.

37
Q

When should recovery begin for midazolam?

A

60 minutes after last incriment

38
Q

Which guidelines should be adhered to when sedating a patient?

A

Concious Sedation Guidelines 2015 (RCS)

Concious Sedation in Dentistry 2017 (SDCEP)

39
Q

Which factors should be looked at during a sedation assessment appointment?

A

Medical history
Dental history
Previous responses to anaesthetic
Recreational drug use
+/- ASA grade

40
Q

Which drugs increase the sedative effect of midazolam?

A

Alcohol
Opiods
Erhthromycin
Anti-depressants
Anti-histamines
Anti-psychotics
Recreational drugs

41
Q

Give an example of an ASA grade I patient.

A

Normal healthy patient, non-smoker, minimal alcohol.

42
Q

Give an example of an ASA grade II patient.

A

Mild systemic disease, but generally well controlled.

(Controlled diabetes/epilepsy/BMI 30-<40)

43
Q

Give an example of an ASA grade III patient.

A

Severe systemic disease, incapacitating and limits life activity.

(COPD, stable angina, BMI >40)

44
Q

Give and example of an ASA grade IV patient?

A

Severe systemic disease which poses constant threat to life.

(Unstable angina, 3 months post MI or stenting, severe COPD)

45
Q

Why is respiratory disease a concern when considering sedation?

A

Almost all sedative agents cause respiratory depression.

Mild disease can be compensated for, however careful consideration is needed.

46
Q

What vital signs should be taken during the sedation assessment appointment?

A

HR
BP
Sats
Weight/height

47
Q

Which medical conditions are aggravated by the stress of dental treatment?

A

Ischaemic heart disease
Hypertension
Asthma
Epilepsy
Psychosomatic illness
Ulcerative colitis
Crohn’s disease

48
Q

What are the patient factor contra-indications to sedation?

A

Severe or uncontrolled systemic disease
Severe mental or physical disability
Severe psychiatric problems
Narcolepsy
Hypothyroidism
Unwilling
Uncooperative
Unaccompanied
Children - for IV
Very old

49
Q

What dental factors may contra-indicate sedation?

A

Procedure too difficult for LA alone - if patient willing
Procedure too long
Spreading infection
Airway threatening
Limits LA
Procedure too traumatic

50
Q

What are the indications for inhalation sedation?

A

Anxiety
Needle phobia
Gagging
Traumatic procedures
Unaccompanied adults
Medical conditions arrevated by stress

51
Q

What are the contra indications for inhalation sedation?

A

Common cold
Tonsilar enlargement
Severe COPD
First trimester of pregnancy
Fear of mask
Patients with capacity issues

52
Q

What is the accuracy rating of the flow control metre used in inhalation sedation?

A

+/-5%

53
Q

What is the purpose of the resevoir bag used in inhalation sedation?

A

Helps to monitor respiration
Holds resevior of gas to properly mix

54
Q

What safety features are present for an inhalation sedation unit?

A

Oxygen flush button
Oxygen montor
Resevoir bag
Colour coding system
Scavenging system
Pressure reducing valves
One way expiratory valve

55
Q

What are the advantages of inhalation sedation?

A

Rapid onset
Rapid peak action
Flexible duration
Rapid recovery
Few side effects
Drugs not metabolised

56
Q

What are the disadvantages to inhalation sedation?

A

Expensive equipment
Expensive gas
Takes up space
Not potent
Chronic exposure risk
Staff addiction
Difficult to determine dose

57
Q

What pre-operative instructions should be given to a patient before inhalation sedation?

A

Eat a light meal
Take medicines as usual
Children accompanied by adult
Don’t drink on day
Arrange childcare
Plan to remain in clinic 30 mins after treatment

58
Q

What should be done before starting inhalation sedation?

A

Set up the machine
Select nasal hood
Connect hoses
Set dail to 100%
Settle patient in chair
Re-explain procedure

59
Q

What flow rate should the inhilation titration be set to before starting to sedate a patient?

A

5-6L per minute

60
Q

How do you begin the process of inhelation sedation?

A

Ensure patient breathing through nose.

Lower tiration by 10% until patient feels different.

Lower by further 10% then wait one minute.

Continue lowing by 5% every minute until desired effect is achieved.

61
Q

What score on the MCDASf of 9 or less indicate?

A

No significant anxiety.

62
Q

What would a MCDASf score of >31 or 5/5 indicate?

A

Extreme dental fear/anxiety

63
Q

What are the four broad methods for managing dental treatment in children?

A

Non-pharmaceutical behaviour management

Local anaesthesia

Sedation

General anaesthesia

64
Q

What types of patients may sedation be indicated for within special care dentistry?

A

Primarily involuntary movement patients, and patients with learning difficulties.

65
Q

What is distribution half-life?

A

The amount of time it takes for the level of a drug in plasma by 50%.

66
Q

What is elimination half life?

A

The amount of time it takes for the level of a drug in the whole body to decrease by 50%.

67
Q

What are the common complications of cannulation?

A

Venospasm
Extra-vascular injection
Intra-arterial injection
Haematoma
Fainting

68
Q

How do you manage venospasm?

A

Time dilating vein
Efficient technique
Warm area during winter

69
Q

How do you manage extra-vascular injection?

A

Manage pain and swelling
Expect delayed absorption
Good cannulation
Test dose of saline
Remove cannula
Apply pressure

70
Q

How do you identify intra-arterial injection?

A

Blood in cannula
Pain radiating distally from site
Loss of colour or warmth

71
Q

How do you manage intra-arterial injection?

A

Monitor for loss of pulse
Leave cannula in situ for 5mins
Symptomatic leave and refer to hospital

72
Q

What are the steps you can take to prevent haematoma when cannulating?

A

Avoid multiple holes in vein
Pressure post op
Careful technique

73
Q

What are the complications that can arise from giving IV sedation (excluding cannulation complications)?

A

Hyper-responders
Hypo-responders
Parodoxical reactions
Oversedation
Allergic reactions

74
Q

What are hyper-responders to midazolam?

A

Deep sedation with 1-2mg of midazolam

Can be identified with slow titration

75
Q

What are hypo-responders to midazolam?

A

Little sedative effect with large dosages

Check cannula, but may be due to BZD tolerance, cross tolerance, or idiopathic.

76
Q

What are paradoxical reactions to sedation, and how do you manage them?

A

Appear to sedate normally
React to all stimuli

Check for LA failure
Do not keep giving sedative agent
Find alternate management technique.

77
Q

What is meant by the term oversedation?

A

Loss of responsiveness and respiratory depression, leading to airway collapse and respiratory arrest.

78
Q

What should be done if a patient is oversedated?

A

Stop treatment
Try to rouse patient
ABC (BLS)
Administer reversal agent (flumazenil)

79
Q

How should flumazenil be used to reverse a patient?

A

200ug then 100ug at minute intervals

Watch for 1-4 hours

Be more careful next time

80
Q

How do you manage respiratory depression?

A

Check oximeter
Stimulate patient
Supplemental O2 2l per minute
Reverse with flumazenil

81
Q

What should you do if a patient has an allergic reaction to midazolam?

A

Rare response, so check latex and elastoplast

Do NOT use flumazenil

Manage as normal allergic reaction (+/- adrenaline)

82
Q

What are the signs of nitros oxide overdose?

A

Patient discomfort
Lack of co-operation
Mouth breathing
Giggle
Nausea
Vomiting
Loss of consciousness

83
Q

How do you manage nitros oxide overdose?

A

Decrease nitros oxide titration 5-10%, keep nose-piece on as without O2 flow there is a risk of hypoxia.

FINALS - Pharmacology (10 decks)

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