IV sedation II Flashcards
Why do we sedate people?
- Control of fear, anxiety and apprehension
- Reduce stress associated with unpleasant/painful procedures
- To control severe gag reflexes
- Treatment of unco-operative patients, including children and those with disabilities (pt has to be at least age 12 and even then considered an advanced procedure)
- To stabilise the blood pressure of patients with hypertension and a history of cardiovascular or cerebro-vascular disease
what are the advantages of IV sedation?
- Given remote from operating site
- Administered as a single dose
- Rapid onset
- Mouth breathing not important
- Patient co-operation less important
- Sedation attained pharmacologically
- Excellent amnesia (however not always best for treating dental anxiety as pt forgot they did well)
- No pollution (comparing to inhalation)
what are the disadvantages of IV sedation?
- No clinically useful analgesia
- Overdose can lead to profound respiratory depression (pt needs to be able to communicate throughout procedure)
- Requirement for cannulation (might need pre-med for the cannular)
- Laryngeal reflexes obtunded/dulled for a short period?
- Occasional disinhibition effects (pt acting inappropriate)
- Occurrence of sexual fantasies
- Pre/post operative instructions must be followed
what are patient management techniques we can use?
Patient Management Techniques
* Time and TLC
* Local analgesia
* Psychotherapy
* Hypnosis – only works if pt is motivated to practice exercises and takes a long time
* Acupuncture – good for gag reflex and low-level anxiety
* Inhalation sedation
* Oral/Transmucosal sedation
* Intravenous sedation
* General anaesthesia
what is the American Society of Anesthesiologists (ASA)
Physical Status Rating?
I A normal healthy patient
II A patient with mild to moderate systemic disease
III A patient with severe systemic disease that limits activity but is not incapacitating
IV A patient with severe systemic disease that is incapacitating and is a constant threat to life
V A moribund patient not expected to live 24 hours with or without operation
which level of ASA do we sedate?
Only sedate patients ASA I or II
On occasion ASA III only after speaking to GP and be in more of a theatre setting
What is asked in a patient assessment for sedation?
- reason pt is unable to have tx under LA with time and TLC to reduce patient anxiety
- MH ( need to know ASA - may need to speak to GP)
- DH
- treatment needed in sedation (eg if multiple visits GA might be more appropriate)
- SH (can they come with an responsible escort, how will they get there, can kids be looked after, able to take time off work?)
- CONSENT
how to reduce anxiety in patients…
- Be calm yourself
- Smile
- Talk to the patient,
- Know their name
- Be alert to body language
- Read the notes
- Stay close, don’t wander off
- Offer praise and encouragement
- Explain what will happen
- End on a positive note
what should be done for patients who are unable to consent for themselves to IV sedation?
- Discuss everything with next of kin
- Discuss treatment with care staff
- Have 2 professionals (doctor/dentist) independently agree that this treatment is in the best interests of the patient
- Named person to sign pre/post operative instructions
- Liase with parents/GP regarding medical history
- Appoint IMCA (Independent Mental Capacity Advocate)
what are the pre-operative instructions for IV sedation?
Pre:
* Nothing to eat 2 hours before but have something light before that
* No alcohol 24 hours before
* Any changes to medication tell us
what are the post-operative instructions for IV sedation?
- Need to go home with someone
- Stay off social media 24 hours
- Don’t sign anything important 24 hours
- Cannot be looking after anyone else
what do we look at for a baseline physical assessment before IV sedation (add other investigations)?
Baseline Physical Assessment
* Colour
* Pulse
* Respiration
* Arterial oxygen saturation
* Blood pressure
* Weight or BMI
* Degree of understanding and co-operation
Other investigations
* Liver function test
* ECG
* Sickle cell test
* FBC
* INR
* Clotting screen
what are the clincal effects of benzodiazepines?
Benzodiazepines
* Anxiolysis – sedation/relaxed
* Sedation
* Hypnosis
* Amnesia
* Anticonvulsant – midazolam
* Decrease in skeletal muscle tone
when would IV sedation be contraindicated?
- Allergy to benzodiazepines
- Pregnancy
- Age (very old/young)
- ASA III, IV, V
- Poor veins
- High (or very low) BMI
- respiratory depression
- acute pulmonary insufficiency
- sleep apnoea syndrome
- severe hepatic impairment
- Not indicated in ex IV drug users as can be traumatic for patient and cannot control what patient has outside for the clinic and drugs like codeine and tramadol cause respiratory depression ect with IV sedation that also causes respiratory sedation – which can lead to respiratory overdose
what drug is commonly used for IV sedation in dentistry?
Midazolam - benzodiazepines
