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4 - sedation > need to know > Flashcards

need to know Flashcards

1
Q

Ideal properties of IV sedation agent

A

Anxiolytic
Sedative as side effect
Quick onset
Quick recovery
Easy to administer
Low cost

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2
Q

How do benzodiazepines work on the NS?

A

Act on GABA receptors in CNS to enhance GABA effects
Prolongs the time for receptor repolarisation
Mimic the effect of glycine on receptors

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3
Q

CV effects of benzodiazepines

A

Decrease BP by muscle relaxation
This decreases vascular resistance
Increased HR due to baroreceptor reflex

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4
Q

Benzodiazepine drug reactions

A

CNS depressants - opioids
Erythromycin
Antihistamines
Alcohol

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5
Q

Side effects of benzodiazepines

A

Tolerance
Dependence
Sexual fantasy

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6
Q

Diazepam disadvantages

A

Pain on injection
Long elimination half life
Risk of rebound sedation
Unpredictable

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7
Q

Dose and pH of midazolam

A

5mg/ml
pH 3.5

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8
Q

Onset and elimination of midazolam

A

Rapid onset
90-150 minutes elimination

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9
Q

Sedation team

A

Operator/sedationist
Second sedation trained person eg dental nurse
Someone else in practice as a runner eg - receptionist
Patients escort present

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10
Q

Advantages of dorsum of hand

A

Accessible
Superficial and visible

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11
Q

Disadvantages of dorsum of hand

A

Poorly tethered
Affected by peripheral vascularisation so may need to warm hand up

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12
Q

How much midazolam administered

A

2mg bolus then 1mg increments every 60s until suitable level of sedation

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13
Q

Signs a sedated patient is ready to start treatment

A

They are willing to start
Verrill’s sign of ptosis
Eve’s sign - loss of motor coordination
Delayed response to commands

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14
Q

General max midazolam dose

A

7.5mg

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15
Q

How long is midazolam pt likely to be sedated

A

30-45 minutes

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16
Q

Recovery steps for IV sedation

A

Escort with pt
60 minutes after last increment of midazolam
Cannula removed before leaving
Ensure pt can walk unaided
Escort given POI

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17
Q

What to do if pt goes into respiratory depression

A

Talk to pt and shake them
Head tilt, chin lift, jaw thrust
Oxygen 2L/min via nasal cannulae
Oxygen, max can give via Hudson mask
Flumazenil
Call an ambulance

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18
Q

Flumazenil dose?

A

500mcg/5ml
Dose 200mcg (2ml) then 100mcg (1ml) every 60s until response is seen

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19
Q

Risk of flumazenil

A

Resedation

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20
Q

Elimination half life of flumazenil

A

50 minutes

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21
Q

Definition of conscious sedation

A

Pt is given a drug which depresses the CNS so verbal contact with the pt can be maintained throughout the period of sedation
The drugs and techniques used should carry a margin of safety wide enough to render loss of conscious unlikely

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22
Q

List 4 cannula complications

A

Venospasm
Extravascular injection
Intra-arterial injection
Haematoma

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23
Q

Venospasm

A

Disappearing vein syndrome
Vein collapse at attempted venepuncture

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24
Q

How to manage venospasm

A

Gets worse at repeated attempts
Slow skin puncture makes it worse - efficient technique
Ask pt to wear gloves or warm hands

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25
Q

Extravascular injection

A

Active drug injected into interstitial space causing pain and swelling
Can delay absorption

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26
Q

How to manage Extravascular injection

A

Prevention by good cannulation and test dose of saline
Treat by removing cannula, applying pressure and reassuring pt

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27
Q

Signs of intra-arterial injection

A

Pain on injection
Red blood in cannula
Weakening pulse
Pain radiating distally from site of cannulation

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28
Q

Avoid intra arterial injection

A

Avoid anatomically prone sites - antecubital fossa
Palpate first

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29
Q

Manage intraarterial injection

A

Monitor for loss of pulse, limb cold and discoloured
Leave cannula in situ 5 minutes post drug
If no problems remove cannula
If symptomatic leave cannula and refer to hospital

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30
Q

Haematoma

A

Extravasion of blood into soft tissues causing bruising
Due to damage to vein walls
Caused at venepuncture or removal of cannula

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31
Q

Haematoma prevention

A

Good cannulation technique
Pressure post-op
Take care with elderly

32
Q

Haematoma tx

A

Time
Rest
Reassurance
Ice pack then moist heat
Heparin gel

33
Q

Complications during sedation

A

Hyper-responders
Hypo-responders
Paradoxical reactions
Oversedation
Allergy

34
Q

What is hyperrespondance and how to prevent

A

Deep sedation using minimal dose
Use 1mg increments when titrating drug

35
Q

Hyporespondance and management

A

Little sedative effect with large doses
Check cannula is in vein

36
Q

Types of tolerance

A

Benzodiazepine induced
Cross tolerance
Idiopathic

37
Q

Threshold to abandon midazolam tx

A

10mg
Can be up to 15 with specialists

38
Q

Paradoxical reactions

A

Pt appears to sedate normally but reacts extremely to all stimuli

39
Q

Paradoxical reaction tx

A

Relax pt when stimuli is removed
Check for LA failure
Reversal agent

40
Q

Oversedation

A

A loss of consciousness
Pt has respiratory depression and loses ability to maintain airway and undergoes respiratory arrest

41
Q

Allergic reaction

A

Do not reverse - pt could be allergic to flumazenil as it is a benzodiazepine
Manage anaphylaxis as if pt is not sedated

42
Q

Complications of IS

A

Oversedation
Patient panics

43
Q

Signs and symptoms of nitrous oxide overdose

A

Pt discomfort
Lack of cooperation
Mouthbreathing
Giggling
Loss of consciousness
Nausea
Vomiting

44
Q

nitrous oxide overdose management

A

Reduce nitrous oxide concentration by 5-10%
Reassure pt
Dont remove nosepiece - can cause diffusion hypoxia

45
Q

Why is drug history important

A

Almost all drugs increase sedative effect of midazolam

46
Q

ASA I

A

Normal healthy patient
Non-smoker
Minimal alcohol

47
Q

ASA II

A

Mild systemic disease

48
Q

ASA III

A

Severe systemic disease
Limits capacity but not incapacitating

49
Q

ASA IV

A

Severe systemic disease
Constant threat to life

50
Q

ASA V

A

Moribund
Not expected to live >24 hours

51
Q

ASA VI

A

Pt brain dead for organ donation

52
Q

Where to treat each ASA class

A

ASA I and II - primary care
ASA III and IV - secondary care

53
Q

Pregnant woman ASA

A

II

54
Q

Vital signs measured in sedation assessment

A

HR
BP
Oxygen saturation
BMI

55
Q

Methods of pain and anxiety management in children

A

NPBM
LA
Sedation
GA

56
Q

Aids to delivering LA to children

A

Behavioural management
Hypnosis and relaxation techniques
CBT
Using the wand

57
Q

Indications for IS in children

A

Age - must be able to sit in chair and breathe through nose with mouth open
Mild/moderate anxiety
Mild asthma
Tx needed in multiple quadrants
Good management of gag reflex

58
Q

Contraindications to IS in children

A

Age - can’t understand concept or breathe through nose with mouth open
High anxiety
Nasal blockage
Previous unsuccessful IS
Intellectual impairment

59
Q

Indications for IV sedation in children

A

Age around 12 - no hard age limit
No/mild anxiety
Helpful for asthma
Previous difficult dental experiences
High volume of tx needed

60
Q

Contraindications for IV sedation in children

A

Age under 12
Anxiety/needle phobic
Intellectual impairments
If child likes to monitor the tx

61
Q

General indications for IS

A

Anxiety
Needle phobic
Gagging
Medical conditions aggravated by stress
Unaccompanied adults requiring sedation

62
Q

General contraindications for IS

A

Common cold
Tonsillar enlargement
Severe COPD
First trimester of pregnancy
Claustrophobia

63
Q

Advantages of IS

A

Rapid onset
Rapid peak action
Flexible duration
No amnesia
Drug not metabolised

64
Q

Disadvantages of IS

A

Expensive equipment
Space occupying equipment
Staff addiction
Possible chronic exposure risk
Difficult to determine actual dose

65
Q

How nitrous oxide is administered

A

Ask pt to signal when they feel different
Reduce oxygen by 10%
Wait 1 minute and repeat
After oxygen reaches 80% reduce by 5% per minute
Stop titration when patient ready

66
Q

How to adjust oxygen in IS

A

If under sedated decrease by 5% increments until satisfactory sedation
If over sedated, increase oxygen in 5-10% increments until satisfactory sedation

67
Q

How to take patient off IS sedation

A

Gradually increase O2 by 10-20% until 100%
100% O2 for 2-3 minutes to prevent diffusion hypoxia
Remove hood and turn gas flow off
Return pt to upright slowly, give praise and reassurance

68
Q

Why is diffusion hypoxia a risk

A

Due to inadequate amount of O2 during or immediately after nitrous oxide administration
Influences the partial pressure of O2 within the alveolus

69
Q

Success rate of IS

A

50-90%

70
Q

CBT

A

Brief psychological therapy - talking therapy
Helps with a range of issues - anxiety, specific phobias
Based on idea our thoughts, feelings and behaviours are all linked

71
Q

Dental anxiety

A

General fear
Occurs without a triggering stimulus
Anticipatory due to previous negative experience

72
Q

Dental fear

A

Intense biological response to immediate danger which is specific to

73
Q

Dental phobia

A

Clinical mental disorder
Debilitating fear
11% prevalence in UK

74
Q

Components of CBT

A

Emotional
Psychological
Cognitive
Behavioural

75
Q

Disadvantage of antecubital fossa

A

Close to branchial artery and median nerve

4 - sedation (10 decks)

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