monitor during sedation Flashcards
advantages of oral sedation
universal acceptability easy to administer low cost involved reduced adverse reactions decreased severity of adverse reactions no special equipment needed
disadvantages of oral sedation
1!! – reliance on patient compliance
prolonged latent period (first pass effect)
erratic absorption from the GIT
inability to titrate
inability to readily lighten or deepen the level of sedation
often prolonged duration of action
prescribe oonly
the dose for the patient to take prior to proceudre
bioavailability
most orally administered drugs have a latent period of approx. 30 minutes – at this time the blood (plasma) level of the drug in at the minium (therapeutic) level
factors acting to influence absorption of the drug from the GI tract
1. lipid solubility ph of gastric tissues mucosal surface area gastric emptying time dosage form of the drug drug inactivatin presence of food in the stomach bioavaliability hepatic first pass effect
anxiety implication
can delay gastric empting – by as much as 2x – which will DELAY THE ONSET of action of antianxiety drugs
administer in oil or aqueous solution
more readily absorbed if given with aqueous solution over oily or capsule form
primary use of oral / rational
managment of anxiety before the dental procedure
strongly suggested that only minimal to moderate sedation be sought via oral route
contrainidaction for oral sedative
dentist must be cpaable of prompt recognition and managment of any adverse reaction that might develop
titration by appointment means
dentist will assess the efficacy of sedation achieved t the first appointment with a given dosage and if necessary, increase or decrease the dosage of drugs administered at subsequent appointments
- over a period of 2-3 appointments 0 the appropriate dosage for that patient can be achieved / titrated
antianiety drugs produce sedation?
no - but level of control over the anxiety of the patient
- antianxiety drugs
- edative -hypnotics
- benxo’s
- nonbenzo’s - histamine blockes
- opiod analgesics
benzo important fact
effective dose and lethal dose is a smaller margin than compared to benzo
LOWER MARGIN OF SAFETY
lower doses of these drugs produce
calming effect (sedation) usually associated with a degree of drwosniness and motor incoordination (ataxia) whereas higher dosages produce hypnosis – state resembling physiologic sleep
examples of benzos used
fluraxepam temazepam triazolam lorazepam midazolam
non benzos are
zoldiem
zaleplon
eszopiclone
chloral derivatives
- chloral hydrate
most popular and common class and effective drug for managemnt of dental fear and anxiety
benzo’s antianxiety agents
benzos act where
subcortical levels of the CNS – actions on limbic system + thalamus
doses smaller than those depressing the reicular activating system - and the cerebral cortex –
- barbs and other s do NOT exhibit selective depression, producing a more generalized CNS depression
benzo in dentistry for
MINIMAL TO MODERATE SEDATINO – DRUG OF CHOICE VIA THE ORAL ROUTE
give ___ the night before
flurazepam and triazolam
give ___ pre treatmetn
oxazepam (acitve metaboite or valium / diazepam) and diazepam
valium aka
diazepam
high safety index
anticonvulsant
skeletal muscle relaant
respiratory nd cardiac depression
has an active metabolite – oxazepam
peak 1 hour
dose 5-10 mg 1 hour before tx
contraindications to valium / diazepam
allergy, psychoses, acute narrow angle glaucoma, pregnancy age under 6
versed aka
midazolam
more potent than valium . diazepam
oral dose = ,5 mg / kg
expensive
water soluble
triazolam aka
halicion
no active metabolites
dose is .125 - 5 mg (.25mg)
anxiolysis
sleep
rapid onset - peak 1 hr
antergrade amnesia
alprazolam aka
xanax
dosage .25 - 1.0 mg
onset 1 hour
duration 1-2 hours
contraindications
- allergy
acute angle glaucoma
glaucoma
non benzos mainly used for
zolpidem (ambien)
zaleplon (sonata)
zopiclone (imovane)
given for anxiety / cant sleep – before any other sedation is given
benzo ANTAGONOIST
flumazenil
competes with beno for the receptr site
uses - reverse CNS respiratory depressant effects
- decrease recovery time
usual dose – .2mg IV over 15 seconds
additional .2 mg prn
repeat q 5 min until recovery or total dose of 1 mg
benadryl / diphenyhydramine
antihistamine with side effect of sedation
- more commoly used with CHILDREN
peak 1 hour
duration 4-6 hours
dose 12.5 - 25 mg
elixir - 12.5 mg/5ml teaspoon
absence of pain the effect of opioids?
produce dyphoria instead of sedation
select medication based on __ and not_
best suit patients age, weight, and medical history, RATHER THAN solely based on the length of time required for the dental tx
prudent to start with a shorter appointment and with treatment that is not too invasive in order to gauge the appropriatness of the chosen sedative agent
amount administered should always be the lowerst effective dose
use __ for 1 hour procedures
zaloplon
moderate length 1-2 hours use
triazolam (halcion) - short acting benzo in the dose of .125 -.5 mg can be given 1 hour before the procedure
2-4 hours
lorazepam (ativan) longer acting can be used
oral sedation appointment - adult patient
previous visit – the suitability of oral sedation is deterimined
day of appt.
- arrive 1 hour before
- sedative drug administered with water
- monitor to start
- wait 45 min then evaluate
- have accompany at all times
- monitors and vtal taken / t minuts
SUPINE
use of nitrous can be considered
good local anesthesia
discharge with escort
courtesy call after
monitoring includes
vitals from start to finish and also recording everything
routine preoperative monitoring
recordkeeping
monitoring can
permit early detection of adverse side effects that may be produceed by drugs or by clinical actinos, inlcuding hemorrhage or underventilation and
allows corrective measures – to be institutted at a time when they are more likely to be effectiveely prevent serious complications from developing
treating urgency – can prevent treating and emergency
when can a apparatus be considered a monitor
only when it delivers an AUDIIBLE or VISUAL warning when the function measured falls outside of predetermined parameters
if no warning - the device is more a measuring instrument than a monitor
monitors designed to measure
CNS
respiratory system
cardiovascular system
temperature
requiremnts of ideal monitoring devices
safe reliable noninvasive easily interpreted display easy to calibrate stable portable inexpensive no technical aid required easily integrated with other monitoring equipment
vital signs pre op must be
blood pressure
heart rate and rythm and respiratory rate
additional - temp, height and weight
pulse tells you
heart rate and rhythm
pulse recommended for
ALL patients as part of their routine preoperative evaluation
values below 6- or greater than 110 beats per min in adult - should be re-evaluated before tx is started
monitor of pulse?
regular intervals is DESIRABLE during parenteral sedation - every 15 minutes or every 5 minutes
continous monitoring of the pulse is MANDITORY for all forms of deep sedation and GA where more profound levels of CNS depression is sought
radial pulse palpable?
systolic pressure at least 80
brachial - at least 70
carotid - atleast 60
if both carotid and brachial pulses are present but radial is not - systolic pressure is greater than 70 but less than 80 mm Hg
monitoring blood pressure is ___ method
second method
asa 4 wit
200 mm hg systolic or 115 mm hg disatolic or higher
requires medical consultation and management BEFORE the start of elective dental or surgical care
blood pressure cuff on same with IV line?
NO
cause machine will constrict them in that area
same with pulse oximeter – not on the same arm
intra arterial blood pressure use?
degree of accuracy is great but not reall needed during outpatient sedation
indicated in both GA procedures involving a greater degree of risk - neuro or cardiac surgery and when the degree of risk pesented by the patient (ASA 4 or 5) is significant
ECG use
monitors noth heart rate and rhythm and provides warning of development of changes in the elctrical activity of the myocardium
standard lead I (right arm – left arm) or lead II right arm – left leg are most commonly used during anesthesia b/c they permit excellent detection during dysrhythmias
what can you NOT use for respiration monitoring
rise and fall of the chest and color of the oral mucous membranes
respiratory monitoring device
precordial - pretracheal stethescope
two things to consider with breathing
rate and soun
tachypnea
indicates presence of anxiety – hyperventilation - pathologic condition – diabetic acidosis and ketosis or elevated CO2 levels
bradypnea
noted after administration of larger doses of the opioid agaonist analgesics
snoring cause and magemnt
hypopharngeal obstruction by the tongue
repeat head tilt and chin lift
gargling cause and managment
foreign matter (blood / wtaer , vomite in airway
suction airway
wheezing cause and management
brochospasm
bronchodilator - via inhalaton - only if conscious IM, IV i unconscious
crowing cause and mamangement
laryngeospams - partial
manage - suction airway + ressure O2
he thinks ___ is most essential in monitoring
pulse oximetry
appearance of dysrythmias with ECG can be due to
during sedation can be due to
hypoxia - leading to myocardial ischemia and
endogenous catecholamine release - secondary to inadequate pain control or too light level of CNS depression
hypoxia levels
arterial O2 saturatino SpO2 of 8^% to 90%
- unsuspected hyoxemia occurs more than we think – study showed 53% in this rang
O2 saturation refers to
amount of O2 carried by hemoglobin
HbO2 and Hb absorb wavelnegths of light at differing degrees - relative percentages of these two hemoglobins ae calculated within the oimeter, and the SpO2 is displaye don the screen
carbon dioxide monitoring
monitor levels of
uses infrared absorption
inspired and end tidal CO2
displays a % or mm HG
audible and visual alarms alert the operator if end-tidal CO2 calues are less than or greater than the selected parameters
less than 23 mm Hg or 3% or greater than 51% or 6.5% or if apnea occurs
implication of temp / fever
can increase the workload of the cardiovascular and respiratory systems
heart and respiratory rates increase with an increase in body temp
the patients ability to tolerate stress decreases
keep recording device in pt. mouth for 3-5 mins
