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Pain and Anxiety > Intravenous Sedation II > Flashcards

Intravenous Sedation II Flashcards

1
Q

Purposes of sedation?

A

Control fear, anxiety, apprehension
Reduce stress associated with unpleasant/painful procedures
Control severe gag reflex
Tx of uncooperative pts, including children and disabled pts
To stabilise BP of pts with hypertension and history of CV or cerebro-vascular disease

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2
Q

Advantages of intravenous sedation?

A 
Given remote from operating site
Administered as single dose
Rapid onset
Mouth breathing not important
Pt cooperation less important
Sedation attained pharmacologically 
Excellent amnesia
No pollution
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3
Q

Disadvantages of intravenous sedation?

A

No clinically useful analgesia
Overdose can lead to profound respiratory depression
Laryngeal reflexes obtunded for a short period?
Occasional disinhibition effects
Occurrence of sexual fantasies
Pre/post op instructions must be followed

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4
Q

Pt management techniques?

A 
Time and TLC
LA
Pyschotherapy
Hypnosis
Acupuncture
Inhalation sedation
Oral/transmucosal sedation
IV sedation
GA
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5
Q

How to minimise anxiety?

A 
Empathy
Kindness
Explanation
Support
Time
Gentleness
Be calm
Smile
Talk to pt, know their name 
Read notes
Stay close
Offer encouragement
Explain what will happen
End of positive note
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6
Q

How to take a medical history prior to sedation?

A 
Written questionnaire completed with pt
Verbal discussion with patient
Contact GP
Liaise with other health care professionals 
Advice from consultants
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7
Q

Dental history prior to sedation?

A 
Attitude to dental care
Past history
Past experience of sedation and GA
Recent history
Main dental problem
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8
Q

What to consider prior to the dental procedure?

A 
Tx required
Length of procedure
Degree of trauma involved
Multiple visits
Acute infection
Degree of pt cooperation required
Radiographs required during tx
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9
Q

What social history to consider prior to the procedure?

A 
Able to provide a responsible escort
Ability to understand and follow pre and post op instructions
Someone to help at home
Able to take time off work
Someone to look after children
Someone to stay overnight
Transport to and from surgery
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10
Q

What is informed consent?

A

Informed consent explains the benefits of tx, risks and disadvantages of treatment and the tx alternatives to the patient in a language that they understand

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11
Q

What to do if a pt is unable to consent for themselves?

A

Discuss everything with next of kin
Discuss tx with care staff
Have 2 professionals (doctor/dentist) independently agree that this tx is in the best interests of the pt
Names person to sign pre/post op instructions
Liaise with parents/GP regarding MH
Appoint IMCA

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12
Q

What needs to be physically assessed prior to IV sedation?

A 
Colour
Pulse
Respiration
Arterial oxygen saturation
BP
Weight or BMI
Degree of understanding and cooperation
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13
Q

What other investigations may you do prior to the sedation?

A 
Liver function test
ECG
Sickle cell test
FBC
INR
Clotting screen
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14
Q

Clinical effects of benzodiazepines?

A 
Anxiolysis 
Sedation
Hypnosis
Amnesia
Anticonvulsant
Decrease in skeletal muscle tone
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15
Q

Contraindications to IV sedation?

A 
Allergy to benzodiazepines
Pregnancy
Age
ASA III, IV, V (requires a hospital setting)
Poor veins
High or very low BMI
Respiratory depression
Acute pulmonary insufficiency
Sleep apnoea
Severe hepatic impairment
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16
Q

What to be wary of with sedation?

A

MANY drug interactions

17
Q

What can midazolam interact with?

A

ACE inhibitors (BP) - Enhanced hypotensive effect
Alcohol - enhanced sedative effect
Alpha blockers - enhanced hypotensive and sedative effects
Antidepressants - enhanced sedative effect
Antihistamines - enhanced sedative effect
Betablockers - enhanced hypotensive effect

18
Q

What equipment is needed for sedation?

A 
Midazolam, note expiry date/batch
Saline for injection 2x5ml syringe
Straight filter needle for drawing up drug
Pre injection swap
Tegaderm patch to secure cannula
22G cannula
Gauze
Yellow sharps box
Tourniquet

Oxygen and emergency oxygen
Cylinder capable of giving 15litres/min

Suction
Emergency suction

Emergency drugs
- Flumazenil

19
Q

What drugs are used to sedate?

A

Midazolam 5mg/5ml (1mg/ml)

Saline for intravenous administration

20
Q

What is the reversal agent for midazolam?

A

Flumazenil/anexate 0.5mg/5ml (100mcg/ml)

21
Q

Normal values of vital signs to compare to the pt?

A 
Weight 70kg
Temp 36-37.5 degrees
Colour pink, well perfused
Pulse 70bmp, full volume, regular
Resp: 12-20 regular breaths per minute
BP 120/180mmHg 16/10KPa
Temperature: Hot and sweaty because unwell or anxious?
22
Q

How to assess the pts level of consciousness?

A 
Stand unaided with eyes closed
Romberg test
Touch nose with forefinger
Loss of facial expression/animated
Eyes open/closed/ptosis
Speech slurred/slow
Response to verbal command
23
Q

Respiratory obstruction?

A

Potentially fatal complication
Can lead to coughing, straining, vomiting and regurgitation
Suspect if snoring, paradoxial chest and abdominal movement, straining
Airway causes (edentulous pts)
Tongue
Can also be caused by swelling, tumour, irradiation, epiglottis, restricted jaw opening

24
Q

Minimal monitoring needed for IS AND IV sedation?

A

For IS - dental team observation
For IV - dental team observation supported by electronic blood pressure and pulse oximeter readings
- Baseline BP should be within normal range for age and physical status
- Pulse oximetry: measures arterial oxygen saturation, non-invasive, accurate

25
Q

What principles is pulse oximetry based on?

A

Difference in absorption spectra of reduced and oxygenated haemoglobin
The beer lambert law
That only reduced and oxy-haemoglobin are present in the blood

26
Q

Paperwork needed for sedation?

A

Written consent
MH
Signed pre and post op instructions
Contemporaneous sedation record sheet

27
Q

Transmucosal sedation?

A

Sublingual
Rectal
Intranasal

28
Q

Transmucosal administration?

A

Avoids venepuncture
Rapid absorption and onset
Drug directly enters systemic circulation, bypasses entero-hepatic circulation
Good pt cooperation
Avoids pollution
Blood levels significantly higher than after oral administration
Once administered effetcs cannot be terminated

29
Q

Transmucosal midazolam?

A

Very bitter taste
ph 3.5 - stinging intra-nasally
Use concentrated formulation
Studies used 0.2-0.5mg/kg for premedication and sedation in children

30
Q

Drugs for oral sedation?

A

Temazepam
Midazolam
Diazepam
Nitrazepam

31
Q

Advantages of oral sedation?

A 
Administered as single dose
Given remote from operating site
Mouth breathing not important 
Pt cooperation less important
Pharmacology rather than psychology 
Good amnesia
No pollution
No venepuncture required
32
Q

Disadvantages of oral sedation?

A 
Slow onset, uncertain effect
No clinically useful analgesia
Once administered effects cannot be discontinued or switched off
Dose is estimated rather than titrated 
Occasional dis-inhibition effects
Pre and post op instructions need to be followed as for IV sedation
Training 
Some drugs cause gastric irritation

Pain and Anxiety (6 decks)

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