Oral Sedation Flashcards by Ryan Davis

Define dental sedation

The reduction or abolition of the physiological and physchological responses to the stress of dentistry without the loss of…

Consciousness
Cooperation
Protective reflexes

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What is iatro-sedation?

When the dentist provides powerful psychological support and “hypnotic” suggestion

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What plane of sedation is conscious sedation in?

Plane 1: amnesia stage

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Plane 2 of anesthesia is under what type of sedation?

General anesthesia

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What are the names for the following planes…

Plane 1
Plane 2
Plane 3
Plane 4

Plane 1 - amnesia stage
Plane 2 - excitement or delirium stage
Plane 3 - surgical anesthesia stage
Plane 4 - medullary paralysis or danger zone

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True or false… you must be trained to only manage the level of plane you are intending to achieve.

False. You must be able to safely manage 1 level of anesthesia beyond plane to be achieved.

If practicing deep sedation you must be able to manage general anesthesia

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What are some medical contra-indications for sedation?

Severe systemic disease 
COPD (except asthma)
Pregnancy
Myasthenia Gravis
Medications such as anti-psychotics 
Severe psychiatric DO
Obesity/bleeding dyscrasias

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True or false… asthma is a contraindication for sedation

False

COPD (except for asthma) is a contraindication

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What are some socio-psychological contraindications for sedation?

Uncooperative, unwilling, unaccompanied pts

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What are some dental contraindications for sedation?

Prolonged difficult surgery

Insufficient personnel

Insufficient resources

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What are 4 different routes of sedation?

Enteral - agent absorbed through GI: oral, rectal, sublingual

Parenteral - agent bypasses GI tract: IV, IM, IN, SM, SC, IO

Inhalation - agent absorbed through pulmonary tree

Transdermal/transmucosal - navel via sublingual/endotracheal tube

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What are the advantages of IV sedation?

Rapid onset of action

Can titrate effect rapidly

Control duration of sedation and high level of efficacy

IV access for emergent therapy

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All types of sedation should have monitoring. What kind of monitoring do you need for IV sedation?

BP, pulse oximetry, ECG, capnography, temperature recording

Time based records at least with recording of 5 minutes apart

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Define capnography

Measures the amount of carbon dioxide in the expired gases. Can identify apnea or airway compromise much earlier than pulse oximetry. Ventilation is the issue

Increases in end tidal carbon dioxide measured through a capnograph precede the decrease in oxygen saturation measured by pulse oximetry

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What are the recommended alarm limits for…

Systolic BP
Diastolic BP
HR (BPM)
SP O2 (pulse oximetry)

Systolic BP: low: 85, high:150

Diastolic BP: low: 50, high: 100

HR BPM: low: 50, high: 110

SP O2: low 92, high 100

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Vital signs should be taken at least every ___ minutes under sedation

5 minutes

BP
HR
Respiratory rate
Capnography readings
Oxygen saturation
Level of consciousness

Sedated pateints must be continuously monitored until discharged

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What are some common sedative combinations?

Benzodiazepine + opioid + inhaled oxygen/nitrous

Midazolam + fentanyl + oxygen

Benzodiazepine + opioid + barbiturate/hypnotic/dissocitative agent + inhaled agent

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What is the key to a successful sedation?

Local anesthesia

If a poor local anesthetic block has been given, the pt will continue to feel pain throughout the procedure

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Lidocaine, prilocaine, and etidocaine are under what category for pregnant females?

category B

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Articaine, bupivicaine, and mepivicaine are under what category for pregnant females?

Category C

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The dentist must be ___ certified to give any sedatives

ACLS

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True or false… you should monitor pts on oral sedatives with pulse oximetry, capnography, BP, HR, EKG because they still have the ability to go into general anesthesia

True

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What are the disadvantages of oral sedation?

Slow onset of action

Pt. Compliance

Low efficacy

Titration of dose unclear

Prolonged duration of effect

Difficulty of administering reversal agents

Meals and drug interaction

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True or false… benzodiazepines give analgesia

False.

They give amnestic qualities, anxiolysis, and seizure prevention

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``` An ASA III pt comes in for an extraction and after administration of fentanyl becomes short of breath with chest pain. All of the following drugs should be considered for a medical emergent situation except... Oxygen Nitrates Versed Morphine ```

Versed

``` All of the following have the propensity to result in GA except... IV sedation Inhalation sedation Rectal sedation Oral sedation All of the above can ```

All of the above have the propensity to develop into GA

What is the most common emergency encountered in dental practice?

Syncope

The initial dose of flumazenil to reverse the effects of midazolam is...

0.2mg

True or false... midazolam is considered 3-5x more potent than diazepam

True

True or false... oral sedation is characterized as a safe method for mild to moderate sedation if if the doses are doubled due to digestion of most of the drug before it acts on the CNS

False

True or false... naloxone is the drug of choice to reverse an opioid overdose. This is substantiated by the relationship between the long half life of naloxone and the short half life of fentanyl

First statement is true Second statement is false

True or false.. antihistamines/barbiturates have problems with efficacy, cost, dosing

True

What are the properties of benzodiazepines?

``` Anti-anxiety Sedative-hypnotic Anti-convulsant Skeletal muscle relaxant Amnesic effect ``` They are NOT analgesic*

Benzodiazepines produce sedation and amnesia. The potentiate ___ receptors. They have a __ onset and emergence

GABA (direct and fast acting Cl-gates causing inhibition in cells). (Acts especially on the limbic system, sleep center, thalamic, and hypothalamic areas of CNS) Slow

Diazepam (AKA ___) is a benzodiazepine. Its peak concentration onset is at ___ minutes. Its half life is ___ hours. Dose is ____ 1 hour prior to appointment. What are its side effects?

Valium 60-90 minutes 20-50 hours (very long acting) 5-15 mg Drowsiness, ataxia, psychomotor impairment with recovery in 2-4 hours Note that it has active metabolites that need surveillance

Triazolam (AKA ___) is given 1 hr prior to appointment because its peak concentration is at ___ minutes. Its half life is ___ hours (no active metabolite). What is its dosing? What are its side effects? What it's its FDA category?

Halcion 60-90 minutes 2. 2 hours (much shorter than Valium) (note that in geriatrics they can suffer from prolonged post operative delirium) 0. 25mg night before. 0.25-0.5mg 1hr prior to appt. (efficacious at low doses) Psychomotor impairment, drowsiness, light-headed, confusion, dream abnormailities FDA level X (do not give to pregnant women)

Midazolam (AKA ___) has its peak concentration after ____ minutes. Its half life is ___ (no active metabolites). What are its side effects?

Versed 30-60 1.5-2.5 hours (short) Respiratory depression**, recovery time shorter than other drugs. Water soluble

True or false... midazolam potentiates the effects of fentanyl that can cause too much respiratory depression

True

True or false.. oxygen is considered a drug

True

What is the reversal for benzodiazepines? What is its onset? What is its half life?

Flumazenil (romazicon) - doses of 0.2mg to a maximum dose of 3mg. Onset is 1-2 minutes. Decreased half-life compared to benzodiazpine half life. Requires monitoring (watch them for the length of the half life of the initial drug, not the reversal agent)

What are some complications associated with benzodiazepines?

Respiratory depression Glaucoma: acute narrow and wide angle Birth defects Valium: thrombophlebitis/extravasation into tissues (because its an oil base)

Diazepam is ___ water soluble and it is metabolized in the ___

Not water soluble -> venous irritation Metabolized in liver -> not redistributed

True or false.. diazepam is used as a premedication for seizures. It is often used for induction

First statement is true Second is false

Clonazepam is ___ water soluble. It has a ___ onset of action. It is not used for induction. It is used as adjunct for anxiolytic and sedative properties

Not Slow

True or false... midazolam (versed) is less potent than diazepam or clonazepam. Its induction is fast and has no ability to depress respirations.

False. It is more potent, it has slow induction, it may depress respirations

True or false. Midazolam has minimal cardiac effects and is water soluble

True

True or false... nitrous has the ability to take the patient all the way to deep sedation

True

True or false... in both oral sedation and inhalation sedation, the patient must have an escort

False. In oral sedation, the pt must have someone take them home after appointment. Inhalation sedation does not require an escort.

What are the advantages of inhalation sedation?

Ease of use Rapid onset of action Ability to titrate effect Analgesic and sedative properties Few drug-drug interactions Rapid recovery No escort or restriction of activities

What are the disadvantages of inhalation sedation?

Decreased efficacy for severely anxious pts. Unpredictable amnesia Nausea/dizziness Sexual hallucinations Chronic exposure to staff (may cause peripheral neuropathy and spontaneous abortions)

What are the contraindications of inhalation sedation?

Pregnancy Severe blockage of nasal passages Head injury* Pneumothroaces Respiratory diseases (COPD, TB, MS, CHF) Severe blocked eustacian tubes

True or false... NO2 is contraindicated in asthma pateints

False. Its actually good for asthma pts because it dilates the airways

True or false... NO2 is poorly soluble in the blood. The deepest plane you shoul try to achieve is plane 1 although it has the potential to go deeper

True

True or false... nitrous oxide is an amnesic and analgesic

True

You should never go above ___% nitrous oxide. What should you do after the procedure?

70% Make sure to turn off nitrous and turn on 100% oxygen for 2-5 minutes to avoid diffusion hypoxia*

Nitrous oxide can cross the placenta during the ___ trimester. It has the potential to alter DNA synthesis so make sure to talk to OBGYN in 2nd and 3rd trimesters. No more than __% nitrous should be administer in this group of pts. Chronic exposure to dentist may cause...

First 50% Peripheral neuropathy and alteration in methionine synthetase

What are the effects of opioids such as morphine, meperidine, and fentanyl?

Depression of ventilation Euphoria Sedation Analgesia Hypotensive secondary to vasodilators properties Compensatory increase in CO: tachycardia

True or false... opioids have strong cardiac effects and causes tachycardia in large doses

False, it has minimal cardiac effects (no myocardial depression) It causes Bradycardia in large doses

What are some side effects of opioids?

Nausea Chest wall rigidity Seizures Constipation Urinary retention Some peripheral vasodilation and histamine release causing hypotension

What is the dosage of fentanyl?

30-50ug fast onset Note that fentanyl and versed potentiates respiratory depression Fentanyl is given first followed by versed. Requires careful titration and oxygen administration

Naloxone is a pure antagonist that reverses analgesia and respiratory depression of all opioids. It acts for about ___.

30 minutes to an hour Must monitor for 60 minutes over dose due to half life

Propofol is a hypnotic agent that mediates activity through ___ receptors. It has ___ analgesia properties. It is eliminated via ____. Emergence is __x faster than barbiturates. What is its initial effect?

GABA No analgesia Hepatic redistribution and to kidney 10x Causes an initial hypotensive effect. Don't give to children because of this severe initial hypotension

Why is propofol not recommended for pediatric use?

Strong initial hypotensive effect and reduced cardiac output

Why is propofol contraindicated in patients who are allergic to egg and soy

Because propofol is in an egg/soy base (also note that because of this, propofol expires quickly)

Propofol has a ___ onset and ___ duration of action. It is a painful injection because....? It causes minimal nausea and vomiting and may cause myocardial depression and peripheral vasodilation (baroreflex not suppressed)

Rapid Short Not water soluble

True or false.. ketamine maintains laryngeal reflexes and skeletal tone (even bronchodilation). It increases HR, BP, and CO

True

True or false.. their is no reversal for antihistamines. Antihistamines may cause motion sickness. Antihistamines provide no seizure protection

True

True or false. Benzodiazepine reversal agents may precipitate seizures.

True