Dental Extraction Flashcards
A 26-year-old female patient is undergoing extraction of two wisdom teeth under sedation. She is otherwise well and has no allergies.
What is conscious sedation?
- Conscious sedation can also be described as moderate sedation.
- It is a “drug-induced depression of consciousness”.
- Verbal contact is maintained throughout the procedure using either
verbal commands or light touch. - The patient remains spontaneously ventilating, haemodynamically
stable and is able to maintain their airway without any interventions such as airway manoeuvres or adjuncts.
What are the key issues when pre-assessing this patient for her procedure?
- The patient should be carefully assessed to confirm her suitability for conscious sedation, with a focus on the airway, cardiovascular and respiratory systems, and body mass index. Relative contraindications to sedation include:
- Morbid obesity.
- Severe comorbidities e.g. cardiovascular disease, liver disease, lung disease.
- Learning difficulties.
- Inability to stay still e.g. resting tremor.
- Severe needle phobia.
- A thorough social and psychological assessment is key; the patient needs to be well informed that she will remain conscious throughout, and therefore be aware of what is going on around her e.g. drilling sounds and voices.
- Patients should be fasted as if they were undergoing a general anaesthetic, in case of the need for airway intervention and induction of anaesthesia.
When carrying out conscious sedation, how can the risks to the patient be minimised?
Choice of agent:
* The choice of drug should be determined by the patient’s comorbidities, the length of the procedure and the anaesthetist’s familiarity with the agent.
- Ideally, only one drug should be used throughout the procedure to decrease the effect of synergism and augmentation of side effects such as respiratory depression when agents are used in combination.
Location:
* Dental procedures are often carried out in remote locations, and the anaesthetist should ensure that they are familiar with both the routine and emergency equipment and drugs, and how to escalate should assistance be required in an emergency.
- An appropriate recovery area should be available prior to the patient’s discharge.
When carrying out conscious sedation, how can the risks to the patient be minimised?
Continued…?
Personnel:
* The clinician carrying out the procedure should not be in charge of sedating the patient concurrently.
- Adequate numbers of trained staff are required including recovery nurses and an anaesthetic assistant.
Monitoring:
* AAGBI monitoring should be used, to include pulse oximetry, cardiac monitoring and non-invasive blood pressure monitoring. End tidal carbon dioxide can be used to monitor ventilation.
- Clinical signs such as the response to verbal and tactile communication should be used, and a trained anaesthetist should be present throughout the whole procedure.
During the procedure, the dental surgeon alerts you to a sudden increase in the volume of blood in the suction and in the patient’s mouth. The patient starts coughing and her saturations decrease to 87%. What is your immediate management?
- Alert the theatre team immediately. This is an anaesthetic emergency, likely aspiration of blood.
- Call for urgent senior help and ask for the airway trolley.
- Suction any excess blood in the patient’s airway and place her in a
head down, left lateral position. - Ventilate the patient using a facemask with 100% oxygen.
- Cricoid pressure can be applied if the patient is not vomiting.
- If there is no improvement, or the patient continues to deteriorate,
intubate and ventilate the patient. Suction the airway using a suction
catheter prior to positive pressure ventilation. - Order an urgent chest x-ray and consider chest physiotherapy/
bronchoscopy if there is any evidence of consolidation on imaging or chest auscultation. - Further management should be directed by the patient’s observations and clinical examination, but there should be a low threshold for critical care input.
