Introduction to IV sedation

Question 1

what would be the ideal aspects of an IV sedation agent?

Answer 1

• anxiolysis
• sedation
• ease of administration
• non-irritant
• quick onset
• quick recovery
• no side effects
• low cost

Question 2

what is the action of benzodiazepines?

Answer 2

Acts on receptors in CNS to enhance effect of GABA
- prolongs time for receptor repolarisation
- mimics effects of glycine on receptors

Question 3

What structural area of BZDs allow them to attach to receptors in the CNS?

Answer 3

The benzene ring

Question 4

What are the effects of sedative agents on the respiratory organs?

Answer 4

Respiratory depression
- CNS depression & muscle relaxation
- decreases cerebral response to increased CO2

Question 5

What are the effects of sedative agents on the cardiovascular system?

Answer 5

• decreased BP by muscle relaxation decreasing vascular resistance
• increased HR due to baroreceptor reflex compensating for BP fall

Question 6

What are some specific drugs that interact with sedative agents?

Answer 6

• antihistamines
• erythromycin
• any other CNS depressants

Question 7

what is the gold standard IV sedative drug used in dentistry?

Answer 7

Midazolam

Question 8

What is the dose of one preparation of Midazolam?

Answer 8

5mg/5ml (pH 3.5)

Question 9

what is the elimination half life of midazolam?

Answer 9

90 - 150 mins

Question 10

where is midazolam metabolised?

Answer 10

liver

Question 11

How does Midazolam compare to Diazepam?

Answer 11

Midazolam is:
- painless on injection
- quicker onset
- quicker recovery
- more reliable

Question 12

Who are the members of the sedation team?

Answer 12

• operator sedationist
• second sedation trainer person (e.g trained dental nurse)
• must also have someone else in practice for reception & as runner
• patients escort present at all times

Question 13

What type of cannula is used?

Answer 13

In-dwelling cannula

Question 14

How might you make it easier to cannulate a patients hand?

Answer 14

Warm up their hand and tourniquet

Question 15

What monitoring measurements are taken during a sedation procedure?

Answer 15

• NIBP every 5-10 mins

non invasive blood pressure

Question 16

What drug can be used to reverse Midazolam?

Answer 16

Flumazenil

Question 17

When midazolam is administered, what are the values/increments?

Answer 17

• Initial 2mg bolus
• Watch for 1 minute to see how patient responds
• Then 1mg increments every 60 seconds until desired sedation (10mg max)

Question 18

What are some signs of the end point of sedation?

Answer 18

• slurring & slowing of speech
• delayed responses to demands
• willingness to accept treatment
• Verril’s sign-ptosis
• Eve’s sign (loss of motor coordination)

Question 19

what is Verril’s sign?

Answer 19

drooping eyelids

Question 20

What is crucial to ensure during sedation?

Answer 20

DO NOT LOSE VERBAL COMMUNICATION OR CONSCIOUSNESS

Question 21

What are the aspects of recovery post sedation?

Answer 21

• keep patient until 60 mins after last increment
• cannula needs to be removed
• ensure patient can walk unaided
• escort given post op instructions

Question 22

what steps do you follow if patient experiences respiratory depression?

Answer 22

• talk, shake
• head tilt, chin lift, jaw thrust
• encourage deep breaths
• give supplemental oxygen (2ml/min nasal cannulae)
• if no improve 5l/min via Hudson mask
• Flumazenil if still no improvement
• Ambu bag
• Airways

Question 23

What is the preparation of Flumazenil used in practise?

Answer 23

500 micrograms in 5 ml

Question 24

What is the dose of Flumazenil given to reverse sedation in practise?

Answer 24

• 200 micrograms initially
• 100 micrograms increments every 60 secs until response seen

Question 25

What is Flumazenils trade name?

Answer 25

Anexate