Oral Sedation Flashcards
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
What is iatro-sedation?
When the dentist provides powerful psychological support and “hypnotic” suggestion
What plane of sedation is conscious sedation in?
Plane 1: amnesia stage
Plane 2 of anesthesia is under what type of sedation?
General anesthesia
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
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
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
True or false… asthma is a contraindication for sedation
False
COPD (except for asthma) is a contraindication
What are some socio-psychological contraindications for sedation?
Uncooperative, unwilling, unaccompanied pts
What are some dental contraindications for sedation?
Prolonged difficult surgery
Insufficient personnel
Insufficient resources
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
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
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
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
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
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
What are some common sedative combinations?
Benzodiazepine + opioid + inhaled oxygen/nitrous
Midazolam + fentanyl + oxygen
Benzodiazepine + opioid + barbiturate/hypnotic/dissocitative agent + inhaled agent
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
Lidocaine, prilocaine, and etidocaine are under what category for pregnant females?
category B
Articaine, bupivicaine, and mepivicaine are under what category for pregnant females?
Category C
The dentist must be ___ certified to give any sedatives
ACLS
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
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
True or false… benzodiazepines give analgesia
False.
They give amnestic qualities, anxiolysis, and seizure prevention
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 hours (much shorter than Valium) (note that in geriatrics they can suffer from prolonged post operative delirium)
- 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
