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Sedation > IV Sedation > Flashcards

IV Sedation Flashcards

1
Q

What is the definition of sedation?

A

A technique in which a drug or drugs produces a state of depression of the CNS, enabling treatment to be carried out but verbal contact with the patient is maintained through the period of sedation.

The drugs and techniques used to provide conscious sedation for dental treatment carry a margin of safety wide enough to render unintended loss of consciousness unlikely.

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2
Q

What are the medical indications for sedation?

A

Think about conditions that are aggravated by stress of dental treatment, which may aggravate the medical condition.

Ischaemic heart disease
Hypertension
Asthma
Epilepsy
Parkinson’s disease
Spasticity disorders
Psychosomatic illness- gagging, persistent fainting, phobias.

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3
Q

What are the dental indications for sedation?

A

Difficult or unpleasant procedure- implants, XLA of third molar, orthodontic extractions in a young person.

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4
Q

What are the dental contraindications for sedation?

A

Procedure too long
Procedure too traumatic
Spreading infection- cannot get numb, compromised airway

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5
Q

What are the medical contraindications for sedation?

A

Severe or uncontrolled systemic Diases
Severe mental or physical disability- cannot communicate or unable to understand sedation
Severe psychiatric problems
Narcolepsy
Hypothyroidism
Intracranial pathology- brain trauma
COPD
Myasthenia Gravis
Hepatic insufficiency
Pregnancy and lactation

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6
Q

What are the social contraindications for sedation?

A

Unwilling
Unco=operative
Unaccompanied
Children- cannot give IV sedation to someone younger than 12
Very old

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7
Q

What is the ASA classification and why is it relevant for sedation?

A

American Association of Anaesthesiology.

We can only treat ASA 1 and 2 for sedation.
- ASA 1- a normal healthy individual.
- ASA 2- A patient with mild systemic disease.

3-6 cannot be sedated.

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8
Q

What type of drug is used for IV sedation?

A

Benzodiazepines- Midazolam.

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9
Q

What is the mechanism of action of Benzodiazepines?

A

Act on GABA receptors in the CNS to enhance the effects of GABA.
This reduces excitability of neurons within the CNS, resulting in impaired cognitive function.

Mimics effect of glycine on receptors.

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10
Q

How are Benzodiazepines able to bind to receptors in the CNS?

A

They have a benzene ring which allows them to bind to GABA receptors.

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11
Q

Describe the effects of sedation?

A

Respiratory depression- CNS depression and muscle relaxation.
- Decreases cerebral response to increased Co2
- Synergistic relationship with other CNS depressants- no one can be taking other CNS depressants.
- Increase respiratory depression in already compromised patients- no COPD.

Cardiovascular
- decreased blood pressure by decreasing vascular resistance
- Increase heart rate due to baroreceptor reflex compensating for BP fall.

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12
Q

What are some potentially unwanted side effects of benzodiazepines?

A

Drug interactions
- Any other CNS depressant
- Erythromycin
- Anithistamines

Tolerance- someone already taking benzodiazepines
Dependence- very addictive

Sexual fantasies

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13
Q

What are the properties of an ideal IV sedative?

A

Anxiolysis
Ease of administration
Non-irritant
Quick onset
Quick recovery
No side effects
Low cost
Amnesia?? Is this a good or a bad thing?

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14
Q

Why is midazolam painless to inject?

A

Soluble in water.

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15
Q

What is the dosage of midazolam used?

A

5mg/5ml.
pH 3.5

Give plus of 1mg and then 1mg every 60 seconds until adequate sedation achieved.

2-5 times more potent than diazepam

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16
Q

How is midazolam metabolised?

A

Metabolised in the liver- patients with hepatic insufficiency cannot be sedated with midazolam.
Extra-hepatic metabolism in the bowel.

Elimination half life is 90-150 minutes.
- less working time but it is safer because patients are sedated for less time.

17
Q

Why is Midazolam preferred to Diazepam?

A

Diazepam is insoluble in water so needs to be mixed with propylene glycol- this can be painful.

Half life is much longer- 43 +/- 13 hours.

Risk of rebound sedation because of metabolites.

Unpredictable response and long recovery.

18
Q

What is the reversal agent of midazolam?

A

Flumazenil- 500mcg in 5ml. Give 200mcg, then 100mcg every 60 seconds until a response is seen.

Very short half life compared to midazolam so there is a risk of re-sedation- 50 minutes.

19
Q

How is the IV sedative given to the patient?

A

Through an in-dwelling cannula.

Must stay in during the whole treatment and ones the treatment has done incase emergency management is required.

20
Q

What sites would you cannulate?

A

Veins in the dorsum of the hand- Basilica, metacarpal, dorsal venous arch.

Can also cannulate the antecubital fossa- basilic vein.

21
Q

Why is cannulation of the antecubital fossa not ideal?

A

Brachial artery and median vein are close to the basilic vein.

Less stable is the patient starts moving around.

22
Q

Why is the dorsum of the hand the gold standard cannulation site?

A

Accessible
Superficial and visible

But be aware that it is affected by peripheral vasoconstriction so may need to warm up hand.

23
Q

If someone experiences respiratory depression during sedation, what would you do?

A

Stop what you’re doing.
Talk to them, shake them, head tilt, chin lift, jaw thrust.
Encourage them to take deep breathes- look for rise and fall of the chest.
2L/min oxygen through nasal cannula.
5L/min oxygen through a non-rebreathing mask.

If breathing still doesn’t improve- give flumazenil.
Have medical emergency equipment available to hand.

24
Q

How much midazolam would you give the patient initially?

A

2mg bolus and then 1mg increments every 60 seconds until suitable level of sedation occurs.

Generally do not go any higher than 7.5mg.

25
Q

What signs would indicate that the patient is adequately sedated?

A

Slurring and slowing of speech
Relaxed
Delayed response to commands
Verrill’s sign- drooping of the eyelids.
Eve’s sign- shut their eyes, arms out wise and if they’re sedated, they not be able to touch their nose.
Patient is willing to accept treatment.

Patient should not lose verbal communication.

26
Q

Roughly how much time would you have for treatment once the patient is sedated?

A

30-45 minutes useful sedation.

27
Q

What readings are taken from the patient before and during treatment?

A

Pre op pulse, blood pressure and oxygen saturation

During treatment
- pulse oximeter- heart rate and oxygen saturation
- NIBP every 5-10 minutes

Acts as an early warning system to allow intervention before emergency develops.

28
Q

When should you assess someone for sedation?

A

At a separate visit to the procedure day.
- gives the patient all the information when they are in a slightly less anxious state and gives them time to digest the information before deciding whether they want to go ahead or not.

29
Q

What is assessed at the assessment appointment for sedation?

A

History- social, dental, medical
Examination- general, oral, vital signs
Treatment plan
Consent
Information for patient and escort

30
Q

What aspects of the social history would you want to know?

A

What are you anxious about?
Are you anxious about everything or is it something specifically about dental treatment?
What do you do for work?
Do you have an escort to bring you, stay with you and take you home?
Do you drink alcohol? How much?
Do you care for anyone?
What type of transport will you be taking home?

31
Q

What aspects of the dental history are important to know?

A

Who has referred the patient?
Previous bad experience?
Any previous sedation or GA? Any problems with this?
Symptoms- acute or chronic?
What is the proposed treatment? Could you get it all done within the allowed time?

32
Q

What medical history questions would you want to know?

A

Full medical history
- if patient fills in the form, go over it with them and ask follow up questions.

Emphasis on drug history, drug allergy, previous anaesthetic/sedation and any issues, recreational drug use.

33
Q

What drugs may increase the sedative effect of midazolam?

A

Alcohol
Opioids- morphine, methadone
Erythromycin
Antidepressants (cause respiratory depression), antihistamines, antipsychotics
Recreational drugs

34
Q

What BP, pulse and oxygen saturation readings would you not want to sedate?

A

Greater than 160mmHg systolic
Greater than 95mmHg diastolic
Greater than 35 BMI
Less than 95% oxygen saturation

35
Q

What are the normal readings for BP, pulse and oxygen saturation?

A

BP- 120/80mmHg
Pulse- 90 beats per minute
Oxygen saturation- greater than 95%

36
Q

If someone is asthmatic, what would you want to know?

A

What drugs do they take for their asthma?
How often do they need to take salbutamol?
Have you been hospitalised in the last year with asthma?
Is your asthma exacerbated by stress?

37
Q

What is pharmacodynamic and pharmacokinetic drug interactions?

A

Pharmacodynamics- Interactions between drugs which have a similar or antagonistic pharmacological effect.
- antidepressants and BDZ’s, antihypertensives and BDZ’s.

Pharmacokinetics- one drug alters the absorption, distribution, metabolism or excretion of another, thereby increasing or reducing the amount of drug available to produce its pharmacological effects.

38
Q

What aspects of examination would you carry out at the sedation assessment appointment?

A

Signs of anxiety- look for signs and also ask what they’re anxious about.
Discomfort with surroundings
Eye contact
Speech

Check vital signs

Brief dental exam to look at what treatment is required.

39
Q

What must you make the patient aware of about the sedation appointment?

A

You must come with an escort- they must remain in the building during the entire treatment and then take you home.
Someone must watch you for at leats 12 hours after the sedation has stopped.
No driving for 24 hours, no operating heavy machinery or kitchen appliances.
No social media, texts or phone calls that day.
Have something to eat afterwards and go to sleep.
No responsibilities when you go home- no kids, not taking care of an elderly person.

Sedation (6 decks)

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