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Sedation > Inhalation Sedation > Flashcards

Inhalation Sedation Flashcards

1
Q

What are the indications for Inhalation sedation?

A

IS can be used in adults and children to help people who have mild to moderate anxiety- doesn’t work on serious anxiety.

Anxiety
Needle phobia
Gagging- one of the gases used is good to reduce the gag reflex.
Traumatic procedures
Medical conditions that are aggravated by stress
Unaccompanied adults requiring sedation
Amenable to hypnotic suggestion- old enough to understand this.
Previous IS which was successful

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2
Q

What are the contraindications for IS sedation?

A

Common cold
Tonsillar/adenoidal enlargement
Severe COPD, intellectual impairment, learning difficulties.
First trimester of pregnancy
Fear of “mask”/claustrophobia
Patients with limited ability to understand- IS sedation relies on the ability of the patient to understand and that they need to breathe in and out their nose.
Severe anxiety.
Procedure at the front of the patient’s mouth.

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3
Q

What equipment is involved in inhalation sedation?

A

Gas cylinders- nitrous oxide and oxygen (separate)
Pressure reducing valves
Flow control meter
Reservoir bag
Gas delivery hoses
Nasal hood
Waste gas scavenging system

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4
Q

What is the flow control meter?

A

Quantified oxygen flow meter- measures flow rates of up to 10L/min- measures how much oxygen you’re getting per minute.

Nitrous oxide flow meter- determines nitrous oxide flow meter- flow rates up to 10L/min.

These flow meters are +/- 5%, so bear in mind that the patient may actually be getting more nitrous oxide than what is being measured.

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5
Q

What other features are present on the control panel?

A

Picture control dial- tells you what % of oxygen the patient is getting- turn it down to give more nitrous oxide.

Flow control knob

Air entrapment valve- if gases fail, valve opens to allow room air into the circuit and the machine will turn off.

Oxygen flush button- flushes oxygen 35L/min for emergency purposes only.

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6
Q

What is the reservoir bag?

A

2 or 3 litre bag- rubber or silicone.

Usually filled with air and emulates the patient’s lungs.
- To get the flow of nitrous oxide correct, you’re using the bag to help with that.
- The bag should move in and out visibly with each inspiration and expiration.
- must not collapse.

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7
Q

What are the gas delivery hoses and nasal mask/hood?

A

Gas delivery hoses- one hose delivers fresh gases from the machine, the other hose delivers waste gas to the scavenging system.
- Non0return valve in expiratory limb prevents rebreathing expired gases.

Nasal mask/hood- connects to the two breathing circuits. Should form a seal around the patients nose.

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8
Q

What is the scavenging system?

A

Collects waste gas- small negative pressure.

Watch for patient mouth breathing, check mask seal to reduce contamination.

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9
Q

What are the safety features in Inhalation sedation?

A

Air entrapment valve
Colour coding
Scavenging system
Reservoir bag
Oxygen monitor
Oxygen flush button
Oxygen and nitrous oxide pressure dials
Pressure reducing valves
One way expiratory valve
Quick fit connection for positive pressure oxygen delivery

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10
Q

What are the advantages of IS?

A

Rapid onset- 2-3 mins.

Rapid peak action- 3-5 mins.

Flexible duration

Rapid recovery

No injections- but still need LA for procedure.

Few side effects to patient

Drug not metabolised

No amnesia

Some analgesia

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11
Q

What are the disadvantages of IS?

A

Equipment expensive

Gases expensive

Space occupying equipment

Not potent- enough fr someone that wants to do the treatment but will no disarm someone if they do not with to go through with the treatment.

Requires ability to breathe through your nose

Staff addiction

Difficult to accurately determine actual dose the patient is receiving

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12
Q

What are the signs of adequate sedation?

A

Patient relaxed/comfortable
Patient awake
Reduce blink rate
Laryngeal reflexes affected
Vital signs unaffected
Gag reflex obtunded
Mouth open on request
Decreased reaction to painful stimuli
Decrease in spontaneous movements
Verbal contact maintained

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13
Q

What are the symptoms of adequate sedation?

A

Mental and physical relaxation
Lessened awareness of pain
Paraesthesia- lips, fingers, toes, legs, tongue
Lethargy
Euphoria
Detachment “floating feeling”
Warmth
Altered awareness of passage of time
Dreaming
Small controllable “fit of giggles”

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14
Q

What are the signs and symptoms of Over-sedation?

A

Repeatedly closing their mouth
Spontaneous mouth breathing
Nausea/vomiting
Irrational and sluggish responses
Decreased co-operation
Incoherent speech
Uncontrolled laughter, tears
Lock of consciousness

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15
Q

What pre-operative instructions would you give someone who is attending for IS?

A

Have a light meal before appointment
Take routine medicines as usual
Children must be accompanied by a competent adult
Adults must be accompanied at their first sedation appointment and afterwards may attend alone
Do not drink alcohol on day of appointment
Wear sensible clothing- no high heals, comfortable clothes
Arrange care of children during and after your appointment
Plan to remain in clinic for up to 30 minutes after treatment.

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16
Q

What should you do post-treatment?

A

Adults may leave unaccompanied at dentist’s discretion.
Child patients must be accompanied by a competent adult.
Prior to discharge, ask the patient how they felt the procedure went and listen.
Patient may feel shivery after IS- reassure patient that this is common and passes quickly.

17
Q

What is the success rate of IS?

A

Published data suggests 50-90%.

Differs depending on patient populations, poorer for patients in pain (increased anxiety state), greater success for orthodontic extractions.

18
Q

Briefly describe the IS technique.

A

Set up machine
Select size of nasal hood- record size in the notes
Connect hoses
Set mature dial to 100% oxygen
Explain procedure to patient
Set flow to 5-6L per minute
Position hood on the patient’s nose
Encourage nasal breathing- check reservoir bag movements.
Reduce oxygen by 10%- get the patient to signal when they start to feel different.
Wait 1 minute and repeat.
After oxygen reaches 80&, reduce by 5% per minute.
Stop titration when patient is ready for treatment.

Constant reassurance and hypnotic suggestion.
Monitor signs and symptoms of adequate sedation
If patient becomes over-sedated increase oxygen in 5-10% increments until satisfactory sedation.

Recovery
- Gradually increase oxygen by 10-20% until 100% or can turn straight to 100%
- Administer 100% oxygen for 2-3 minutes.

19
Q

What 3 things must remain in place throughout sedation?

A

Verbal communication with the patient

Pt remains conscious

Pt retains protective reflexes

20
Q

What aspects of paeditric assessment would you want to do prior to sedation?

A

A- History
B- Patient factors
C- Goals
D- Treatment plan

21
Q

What aspects of history would you want to know in a paediatric patient who is being considered for sedation?

A

Pain- what is their pain level? This will affect timing of treatment and options that you offer the patient.

Nature of anxiety- what is it that they’re anxious about?

Dental history- previous GA’s or sedation? Previous dental treatment attempted under LA?

Medical history- determine level of anxiety and also fitness for sedation.

22
Q

What aspects of patient factors are important to consider in a patient you’re considering for IS?

A

Co-operation- hypnotic suggestion is very important.
Understanding
Coping style- are they a blunter or do they want to know everything?

23
Q

What tools might you use to assess a child’s anxiety?

A

Modified child dental anxiety scale- answers to questions range from a procedure that a child would not worry about to a procedure that would make the child feel very upset.

Can be done in children over 8 years old.

greater than 31 or 5/5- extreme dental anxiety.

24
Q

Why are goals important to establish prior to sedation?

A

Important that the goals of the child, parent and clinician align.
- do they want to fix the anxiety or do they want a quick fix?

25
Q

What aspects of the treatment plan need to be determined at the assessment appointment?

A

The mode of treatment delivery.

NPBM- hypnosis, CBT, tell show do.
LA
Sedation
GA

26
Q

Your patient has just completed a MCDASf. How would you explain your findings?

A

Firstly thank Callum for completing the questionnaire.
Tell him that it is important for you as a dental team to learn about Callum’s worries and fears so you can do better to help him.
Dental fear and anxiety is common, lots of people have it.
Callum’s score is 23, this suggests moderate levels of DFA.
Some scores are higher than others- highest score given to the questions relating to having a tooth taken or an injection in the gum.
Callum should be asked about the current treatment needed, his goals for this, previous treatment and how he coped, any thoughts, feelings, physical symptoms and behaviours that he has experienced in relation to DFA>
Medical history checked for attendance anywhere else for general anxiety issues.

27
Q

If treatment is indicated under LA, what other methods must be used?

A

Behavioural management- role modelling, voice control, tell-show-do, enhanced control, distraction, snozelan environment.
- CBT
- Hypnosis
- Using the wand

28
Q

What gases are used in IS?

A

Nitrous oxide and oxygen

29
Q

What other management strategy is required for IS?

A

Behaviour management

30
Q

What aspects of the consent procedure do you need to go over with the patient?

A

Check understanding of both the patient and the parent- explain the child will feel floaty/tingly, still be awake, will be back to normal a few minutes after treatment, will still need LA.

Pre-op instructions- can eat before the appointment but nothing too heavy, if the accompanying adult is pregnant then they cannot come in to the room during the procedure, if patient has a blocked nose on the day of the appointment, then treatment cannot go ahead that day.

Post-op instructions- no contact sports, can’t ride a bike, they need to be supervised for the rest of the day- can still go to school but the teacher needs to be aware that they have had sedation.

31
Q

What IV sedative is used in paediatric patients?

A

Propofol

May also use midazolam in adolescents but the behaviour can be unpredictable so case selection is crucial.

Post-procedural amnesia is common.

32
Q

What are the indications for IV sedation in a paediatric patient?

A

Age- 12 and above.
Moderate to severe anxiety
Medical conditions where anxiety can precipitate the condition.
Previous dental history- coped well with sedation previously.
Dental needs- high volume of treatment required.

33
Q

What are the contraindications for IV sedation in a paediatric patient?

A

Age- under 12
Anxiety level- severe anxiety, needle phobia.
Medical considerations- intellectual impairment, psychiatric disorders, myasthenia gravis, COPD.
Dental needs

34
Q

How is propofol administered for IV sedation in a paediatric patient?

A

Target-controlled infusion sedation.
Administered by an anaesthetist.
Useful for very long and very short procedures.
Mean rapid onset and recovery.

35
Q

What things should the patient and parent be aware of during the consent process for IV sedation?

A

Check understanding- canola in the back of the hand, they might not remember the procedure.

They must be accompanied by someone, they must stay present during the procedure and take them home in a car or taxi afterwards.
No strenuous exercise for 24 hours.
No alcohol or sedative drugs without medical advice.
Do not make big decision.
No social media posting, no texts, no phone calls.

36
Q

What alternative techniques are available, other than IV and IS?

A

Oral and transmucosal sedation- midazolam, less controlled.

GA

Sedation (6 decks)

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