Lecture 6 Flashcards
Anesthesia
What does continual mean?
Repeated regularly and frequently in steady succession
What does continuous mean?
prolonged without and interruption at any time
What does time oriented anesthesia record mean?
documentation at appropriate time intervals of drugs, doses, and physiologic data obtained during patient monitoring
What does immediately available mean?
On site in the facility and ready for immediate use
What are the types of unconscious anesthesia techniques?
general anesthesia, inhalation general anesthesia
What are the types of conscious anesthesia techniques?
iatrosedation, hypnosis, local anesthesia, oral/rectal, nitrous oxide, intramuscular/intranasal, IV
Definition of pain
unpleasant sensory or emotional experience associated with actual or potential tissue damage or described in terms of such damage
Definition of analgesia
absence of pain in response to a stimulus that is normally painful
definition of anesthesia
absence of sensory modalities
definition of nociception
neural process of encoding noxious stimuli
definition of paresthesia
abnormal sensation, whether spontaneous or evoked
What is ASA I?
Healthy patient
ASA II
Mild systemic disease, patient in use of drugs
ASA III
Severe systemic disease with definite functional limitation, not incapacitating controlled by drugs
ASA IV
Severe systemic disease, with constant threat to life, incapacitatin
ASA V
moribund patient, unlikely to survive 24 hours
What are relevant tests for people taking anti-coagulants?
INR, bleeding time, PT/ aPTT, Platelet count
What is oxygenation
amount of oxygen contained in blood by hemoglobin, expressed in percentage as “Sp02”, measured by pulse oximetry and observation
What is ventilation
active exchange of inhaled and exhaled gases through respiration
What is circulation
cardiac output measured in both blood pressure and heart rate
What is minimal sedation
minimally depressed level of consciousness, produced by pharmacological method, that retains the patient’s ability to maintain an airway and respond normally to tactile and verbal command. ventilatory and cardiovascular functions are unaffected
what is moderate sedation?
when the patients respond purposefully to verbal commands, with light tactile stimulation, no interventions are required to maintain the patient airway, and spontaneous ventilation is adequate
what is deep sedation?
a drug induced depression of consciousness during which patients cannot be easily aroused by respond purposefully following repeated or painful stimulation. Independent ventilatory function may be impaired and patients may need assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate
What is general anesthesia?
drug induced loss of consciousness during which the patient is not arousable, even by painful stimulation and ability to have independent ventilation is impaired. positive pressure ventilation may be required.
What team is needed to perform minimal sedation?
dentist and assitant
What team is needed for moderate sedation
permitted dentist (dentist wtih moderate sedation permit) and dental assistant who can assist in emergency
What team is needed for deep sedation/GA?
Operating dentist, dedicated anesthesia provider for peds, GA trained dentist and 2 assistants for adults
define enteral
any route in which the agent is absorbed through the GI, first pass hepatic metabolism before affects are felt, seen, or measured
define parenteral (par-around) (enteral-GI system)
any route in which the agent bypasses the GI system, agent enters blood stream directly
what is considered a minor patient
13 years or younger
Do you need a different requirement for GA if you are working on a patient that is younger that 13 years old?
yes
What does a moderate sedation permit require?
precordial stethoscope, capnography, needs two additional support personnel other than operating dentist, operating dentist and one support personnel must have PALs certification
What is the training for pediatric minimal sedation?
- 24 hours of pediatric minimal sedation instruction in addition to one clinical case
- completion of CODA approved residency in pediatric dentistry
What is the pediatric minimal sedation agent limit?
dentist shall be limited to administering a single drug whose primary purpose is sedative via the oral route, and not exceed the manufacturer’s maximum recommended dose, plus a mix of nitrous oxide and oxygen.
if you have an oral conscious sedation permit for minors, what can you do/
provide, by definition, oral sedation to “moderate” levels for <13y.o
- can use multiple oral agents
- can use nitrous oxide alongside
- can exceed the FDA MRD (Manufacturer’s recommended dosage)
What can you do if you have a pediatric minimal sedation permit?
- restricted to one sedative only at or below the FDA MRD
- can use nitrous oxide
- can employ adjunctive agents for other therapeutic uses
- use monitoring consistent with minimal sedation
What do you need to be competent in to be able to have a moderate sedation permit for adults?
- need to take a CE course that fulfills the ADA guidelines (60 hours didactic, 20 live-patient experiences)
- be competent in starting an intravenous line
- be able to rescue from unintended deeper level of sedation
What is the adult dosage for adults for diphenhydramine/
25-50mg oral
What is the pediatric dosage for diphenhydramine/
5mg/kg/24hr not to exceed 300 mg
What is the adult dosage for hydroxyzine
50-100 mg oral
What is the pediatric dosage for hydroxyzine
0.6-2.2mg/kg
What is the adult dosage for doxylamine?
5-10mg oral
What is the pediatric dosage for doxylamine?
- 1.9-3.125 mg (2-6 y.os)
* 3.75-6.25mg (6-12 y.os)
What is the duration for diphenhydramine?
15-60 minutes
What is the duration for hydroxyzine?
15-60 minutes
What is the duration of doxylamine?
60-120 minutes
what is the adult dosage for triazolam?
0.125-0.5mg
What is the pediatric dosage for triazolam?
no recommendations for pediatric use
what is the adult dosage for lorazepam?
0.25mg-4.0mg oral
What is the pediatric dosage for lorazepam?
no oral recommendation for pediatric use
What is the adult recommendation for diazepam?
2-10mg oral
what is the pediatric recommendation for diazepam?
1.5-2.5mg orally
What is the pediatric recommendation for midazolam?
0.25-1.0mg/kg oral
What is midazolam usually mixed with when giving to kids?
syrup
What is the onset for triazolam?
15-30 minutes
What is the duration for triazolam?
2-4 hour duration
What is the onset for lorazepam?
30-60 minutes
What is the duration for lorazepam/
> 3 hour procedures
What is the onset for diazepam?
20-40 minutes
What causes diazepam to have a prolonged duration?
due to enterohepatic circulation
what is the onset for midazolam?
10-20 minutes/ .5-1 hour with common 0.5mg/kg dose
What are the common benzodiazepines that we use in dentistry?
triazolam, lorazepam, diazepam, diazolam
what are common non-benzodiazepines that we use in dentistry for anxiety?
- eszopiclone (lunesta)
- zolpidem (ambien)
- zaleplon (sonata)
What is the adult dosage for eszopiclone (lunesta)
1-3mg oral
What is the adult dosage for zolpidem?
5-10mg oral
What is the adult dosage for zalepon (sonata)
5-20mg
What is the onset for eszopiclone (lunesta)
30 minutes
what is the onset for zolpidem?
30 minutes
What is the onset for zaleplone?
20 minutes
What common non-benzodiazepines work best for patients that are pregnant and anxious in the chair?
- zolpidem
- zaleplon
Why is it not recommended for pediatric patients to use alpha 2 agonists?
because of their significant prolonged hypotension
What is the risk for patients taking alpha 2 agonists?
at risk for orthostatic hypotension
What are alpha 2 agonist?
- clonidine
- tizanidine (zanaflex)
- guanfacine (tenex)
what is the use of clonidine?
Antihypertensive
What is the use of tizanidine
antihypertensive, muscle relaxant
what is equipment is necessary when a patient is undergoing GA and you need to monitor them?
- electrocardiogram
- continuous blood pressure monitoring
- continuous oxygen saturation
- respiration and end-tidal CO2 monitoring
What are the typical endodontic patients that you see in the OR?
- Local anesthesia failure
- endodontic surgery
- pediatric referal (newly erupted first molars, extensive decay)
- endodontic involvement of multiple teeth
- fear and anxiety
What are typical periodontal patients that you seen in the OR?
- Local anesthesia failures
- extensive surgical treatment
- fear and anxiety
what info is involved with a patient assessment for advanced pain and anxiety control?
- age, complete medical history
- current/past medications
- previous surgeries, complications
- body weight, habitus
- exercise tolerance
- estimate surgical length/involvement
- post-operative pain control, surgical follow-up
What are questions you should ask for a patient that is about to undergo dental surgery?
Have you had any previous surgeries? How did you recover before? Were there any complications post-op?
If your patient is elderly and has limited ambulation, what should you be wary of?
- prolonged recovery, -safety in ambulation/transport
- Post-operative pain control, GI disturbances, problems with voiding
What should be wary of with patients with complex medical histories?
- Management with consulting healthcare providers
- specific therapies needed
- increased risk of complications such as the use of anesthesia and surgical aspects
Do we ask for physician consultation or clearance?
consultation
What assessments should we ask the physician?
- cardiovascular, pulmonary, hepatic, renal status and or compromise
- previous surgical or procedural history
- modification to prescribed medications
- modification to post-operative pain medications,
- request to optimize patient prior to surgery
- “please provide information regarding”
What other additional information would you suggest from the physician?
- imaging (CT, MRI, echocardiogram, electrocardiogram)
- previous reports (surgical reports, radiology reports, cardiology reports)
- hematology modifications, appointments (factor 8 supplementation, cryprecipitate, PRP advisories)
- additional lab testing 9coagulation, viral load, CBC)
what should you do before scheduling a patient?
- ascertain treatment goals (multiple visits? appliances, prostheses, surgical stents, imaging, patient is informed of surgical involvement/costs)
- consultation with anesthesia, surgical staff (discuss patient’s needs and surgical demands, prepare patient for surgery and time frame)
- scheduling with surgical staff, anesthesia (currently on tuesdays or thursdays)
What is the patient pre-op instructions and consents needed prior to the OR?
- Explain ALL treatment options prior to scheduling (IV moderate sedation, oral sedation, general anesthesia)
- informed consent (risks/benefits of anesthetic choice, treatment course, aware that procedure is not risk free)
- patient is aware of costs and insurance coverage
What are the pre-op instructions for patients in the OR?
- capable and responsible escort to drive patient home
- ensure post-op instructions are being followed
- report post-operative complications
- explain dosing and schedule of post-op pain medications
- administer post-op medications/provide post-operative care
What is NPO status?
nothing by mouth
What is the ideal NPO status for patients entering the OR?
Ideally 6 hours solids, 4 hours clear liquids, violations will result in cancellation and high aspiration with dental surgery
What is a conservator?
Court appointed authority to make healthcare decisions for a patient.
What is moderate sedation
the patient is awake and response and will have no recollection of the procedure
What are treatment goals with a patient with moderate sedation
reduction of stress/anxiety/pain
-want to control hypertension, vaso-vagal syncope, tachycardia, hyperventilaltion from anxiety
If the patient is undergoing moderate sedation, what kind of monitoring is required?
- patient must be responsive to voice
- check pulse oximetry (measures percentage of oxygen in blood, pulse rate)
- non-invasive blood pressure
- capnography: continuous measurement of exhaled CO2
What are common moderate sedation drugs?
- benzodiazepines
- opioid analgesic
what is used to reverse benzodiazepines?
flumazenil
What is used to reverse opioid analgesic?
naloxone
Is benzodiazepines an analgesic?
no
What are adjunctive drugs that are anti-inflammatory steroids?
- dexamethasone
- hydrocortisone
- tramcinalone
What are common non-steroidal anti-inflammatories that are used in conjunction after an OR visit for a patient?
keterolac, acetominophen
What is an antiemetic that we can provide a patient after an OR visit?
ondasetron (zofran)
What IV fluids should we give to the patient after an OR visit?
normal saline (0.9%)
lactated ringers solution
dextrose 5%
Dextrose 5% in lactated ringers
what should we ensure in the immediate pre-operative period?
- consents
- escort availability
- post-operative course
- pre-medication
- post operative pain management
- follow up appointment scheduling
- length of procedure
- payment
prior to beginning treatment, what should you make sure that you check/have in for your OR visit?
oxygen, suction, reversal/rescue medications, adequate monitoring
What are the risks/benefits for patients that are intubated?
sore throat, deeper plane of anesthesia, inability to accurately duplicate “awake” occlusion
What are the risks/benefits for patients that are non-intubated?
aspiration risks, loss of airway, instability of mandibular procedures
At the conclusion of the OR visit, what should you do?
stay with the patient:
- evaluate surgery
- provide post op instructions
- assess post op pain
- provide post-operative pain medications, prescriptions,
- ensure hemostasis, restorative function,
- provide same information to escort/guardian
what should the next appointment be for the patient?
surgical post-op visit, treatment under anesthesia, appliance delivery, restorative treatment
