IV Sedation Flashcards
Dentistry is mostly in what stages of sedation?
Minimal to moderate
Minimal IV sedation is used for ___
Moderate sedation is used for ____
Anxiolysis
Conscious sedation
The minimal number of available personnel for sedation should be ___. what are their roles?
3
Operator (performs procedure) (must be ACLS certified)
Assistant (aids the operator) (must be BLS certified)
Monitor (watches vitals, and should recognize associated complications)
*one of the individuals must be capable of establishing a patient airway and positive pressure ventilation
What is the most common thing people die of during sedation?
Not breathing
True or false.. depending on the patient, they can go from minimal to general sedation pretty quickly
True
Describe the effects that minimal sedation (anxiolysis) has on responsiveness, airway, spontaneous ventilation, and cardiovascular function.
Responsiveness: normal response to verbal stimulation
Airway: unaffected
Spontaneous ventilation: unaffected
Cardiovascular function: unaffected
Describe the effects that moderate sedation (conscious sedation) has on responsiveness, airway, spontaneous ventilation, and cardiovascular function.
Responsiveness: purposeful response to verbal or tactile stimulation
Airway: no intervention required
Spontaneous ventilation: adequate
Cardiovascular function: usually maintained
Describe the effects that deep sedation has on responsiveness, airway, spontaneous ventilation, and cardiovascular function.
Responsiveness: purposeful response following repeated or painful stimuli
Airway: intervention may be required
Spontaneous ventilation: may be inadequate
Cardiovascular function: usually maintained
Describe the effects that general anesthesia has on responsiveness, airway, spontaneous ventilation, and cardiovascular function.
Responsiveness: Unarousable even with painful stimuli
Airway: intervention often required
Spontaneous ventilation: frequently inadequate
Cardiovascular function: may be impaired
Minimal sedation (anxiolysis) is a drug-induced state during which patients respond _______. Although cognitive function and physical coordination may be impaired, ___, ____ , and ____ functions are unaffected.
Normally to verbal commands
Airway reflexes, ventilatory, and cardiovascular functions
Moderate sedation (conscious sedation) is a drug-induced depression of consciousness during which patients respond ____ to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a ___, and _____ is adequate. ____ function is usually maintained.
Purposefully
Airway
Spontaneous ventilation
Cardiovascular
Deep sedation is a drug-induced depression of consciousness during which pts cannot be easily aroused but respond _____. The ability to independent maintain ____ may be impaired. Pts may require assistance in maintaining a ____ and sponteous ____ may be inadequate. Cardiovascular function is usually maintained.
Purposefully following repeated or painful stimulation
Ventilatory function
Patent airway
Ventilation
General anesthesia is a drug-induced loss of consciousness during which pts are not ____, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Pts often require assistance in ___ and positive pressure ventilation may be required because of depressed ____ or drug induced depression of neuromuscular function. ____ function may be impaired.
Arousable
Maintaining patent airway
Spontaneous ventilation
Cardiovascular
Practitioners intending to produce a given level of sedation should be able to rescue pts whose level of sedation becomes deeper than intended. Individuals administering moderate sedation should be able to rescue pts who enter a state of ___. Those administering deep sedation should be able to rescue pts who enter a state of ___
Deep sedation
General anesthesia
What precautions should you take with pts who have cardiopulmonary disease?
Cardiopulmonary disease may accentuate hemodynamic/respiratory depression caused by sedatives and analgesics. May require decreased drug dosages; EKG monitoring warranted.
Hepatic or renal abnormalities may impair ____, causing altered ____ and ____ when sedatives/analgesics are administer.
Drug metabolism
Sensitivity and duration of action
Alcohol/illicit substance abuse may ___ tolerance to sedatives/analgesics while acute use prior to conscious sedation will be ____ with medication effects.
Increase
Additive or synergistic
How does tobacco use affect sedation?
Increases airway irritability and risk for bronchospasm during sedation
The patient undergoing conscious sedation should have a thorough airway assessment focusing on what four things?
Airway class
Mouth opening
Thyromental distance (distance form chin to thyroid)
Rand of motion of the neck
What is the mallampati classification?
Evaluation of the exposed uvula and soft palate when pt is sitting upright, mouth open, and tongue maximally procured WITHOUT speaking or saying “ahh”
Describe mallampati class 1
Soft palate, uvula, pillars visible
This individual should be easy to mask, ventilate, or incubate with a laryngoscope and endotracheal tube
Describe the mallampati class 2
Soft palate and uvula are visible (no pillars)
This individual should be easy to mask, ventilate, or incubate with a laryngoscopes and endotracheal tube
Describe the mallampati class 3
Soft palate, base of uvula visible
This indivial may be hard to mask, ventilate and incubate
Describe the mallampati class 4
Soft palate not visible at all
This classification is very difficult to intubate
True or false…
Used alone, the mallampati tests have limited accuracy for predicting the difficult airway and thus are not useful screening tests. The mallampati classification is only one of 11 non-reassuring findings during airway examination
True
What are some nonreassuring findings during airway PE?
Long upper incisors
Prominent overbite
Pt cannot bring mandibular incisor anterior to maxillary incisors
Interincisor distance less than 3cm
Mallampati class 3 or 4
Palate highly arched or very narrow
Thyromental distance less than 3 finger breadths
Short neck length
Thick neck circumference
Pt cannot touch tip of chin to chest or cannot extend neck
What is the thyromental distance?
Measures the distance between chin and thyroid cartilage (should be at least 3 finger breadths)
True or false. You really should only sedate ASA 1 or 2
True
What is the minimum fasting period for…
Clear liquids
Breast milk
Nonhuman milk
Light meal
Fatty/meaty meal
Clear liquids = 2h
Breast milk = 4 h
Nonhuman milk = 6h
Light meal = 6h
Fatty/meaty meal = 8 or more hours
How does a pulse oximeter work?
Transcutaneous measurement of the ratio of venous to are their land blood. Done by % absorption of light waves length of 660 and 940nm
O2 saturation is calculated by a mathematical algorithm
Assumes absence of methemoglobin and carboxyhemoglobin
Delayed information (1-2 minutes)
A pulse oximetry has a false reading in what circumstances?
Low body-core temp
Vasoconstriction
Hypotension
Deep skin pigmentation
Methemoglobinemia
Carboxyhemoglobinemia
Nail polish*
The mathematical algorithm used in a sphygmomanometer ___ high blood pressure and ___ low blood pressure
Underestimates
Overestimates
When in doubt, use a manual sphygmomanometer
Capnography is a measurement by ____.
Infrared spectroscopy
Waveform tracks “absorption peak CO2” at 4200nm wavelength
Real time graphic assessment gives visual demonstration of ventilatory status
Can be “end tidal” or transcutaneous
What are the limitations of capnography?
In non-closed system (not intubated), using a modified nasal cannula or nasal hood, measurement may be inaccurate due to missing of expired air and dead space.
This is mandatory for deep or general anesthesia
Normal ETCO2 in the adult patient should be ____mmHg
35-45
Hypoventilation > 45mmHg
Hyperventilation < 35 mmHG
This is a direct measurement of ventilation in the lungs
It indirectly measures metabolism and circulation
Opioids provide analgesia and sedation. It ___ cough reflexes. It is ___ lipid soluble. It is metabolized in the ___.
Depresses
Highly lipid soluble (rapidly distributed to tissues and produce long-lasting effects by accumulation in fat reservoirs)
Liver. (Some active metabolites are excreted via the kidneys)
What are four adverse effects of opioids?
Decreased respiratory drive
Potential increases in PCO2
Alterations in hemodynamics and bradycardia
GI upset and itching (constipation)
Elderly and pediatric pts are often more sensitive to the effects of opioids. Why?
Elderly have decreased hepatic and renal function
Pediatrics have immature BBB and renal function
A standard way of evaluating opioid potency is to compare equianalgesic doses of a drug with morphine. Compare morphine to meperidine, hydromorphone, and fentanyl.
Morphine is 10x more potent than meperidine
Morphine is 10x less potent than hydromorphone
Morphine is 100x less potent than fentanyl
Benzodiazepines enhance ___ transmission in CNS. Most are ___ soluble (except __). What are its effects?
GABA
Lipid (except midazolam)
Effects: amnesia, anticonvulsant, anxiolytic, behavior disinhibition
Benzodiazepines may cause dose-related ____ depression, ___ and ____, particularly in the elderly. Midazolam administered rapidly is likely to produce ___.
Respiratory depresssion
Hypotension
Tachycardia
Apnea
True or false… benzodiazepines are generally contraindicated in pregnancy. Diazepam and lorazepam may cause thrombophlebitis
True
What is the elimination half life of diazepam?
20-70 hours
True or false… propofol has analgesic properties
False. It has sedation and amnesia effects
True or false… ketamine is an NMDA antagonist. It causes dissociated anesthesia. It is a potent pain reliever
True
____ is an opioid antagonist which binds to CNS opioid receptors to displace opioid agonists. It reverses respiratory depression and sedation associated with opioids. It may be displaced from CNS receptors by additional doses of opioid. Its half life is shorter than opioids
Naloxone
What is the reversal agent used for benzodiazepines?
Flumazenil
Reverses sedation, respiratory depression and paradoxical agitation, and causes cessation of amnesia following its administration
What are the reversal agents for propofol and ketamine?
They have NO reversal agents
