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oral sedation Flashcards

1
Q

What to consider when determining the need for sedation?

A
  • assessment of dental needs
  • patient cooperation
  • oarental cooperation and involvement
  • economic considerations
  • alternative tx plan
  • pre-operative health eval
  • preoperative behavioral assessment
  • traning and experience of doctor and staff
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2
Q

what are the goals of sedation?

A
  • cooperative and comfortable
  • decrease anxiety
  • improve comfort of doctor and staff
  • minimize hospitalization
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3
Q

what are the advantages of oral sedation?

A
  • unverisal acceptability
  • ease of administration
  • low cost
  • decreased incidence of adverse reactions
  • decreased severity of adverse reactions
  • no needles or syringes or equipment
  • no specialized training
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4
Q

what are the disadvantages?

A
  • reliance on compliance of patient
  • prolonged latency period
  • erratic and incomplete absorption of drugs
  • inability to titrate
  • inability to readily lighten or deepned level of sedation
  • prolonged duration of action
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5
Q

what are the factors influencing the absorption of drugs from the GI tract?

A
  • lipid solubility
  • pH of stomach
  • mucosal surface area
  • gastric emptying time
  • dosage form of drug
  • drug interaction
  • presence of food in stomach
  • bioavailability of drug
  • hepatic first pass effect
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6
Q

What is hepatic first pass effect?

A

the rapid uptake and metabolism of an agent into inactive compounds by the liver, immediately after enteric absorption and before it reaches the systemic circulation. The concentration of a drug is greatly reduced before it reaches the systemic circulation.

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7
Q

What are the characterisitics of conscious sedation level 1 for pediatric dentistry?

A

decrease anxiety, facilitate coping skills

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8
Q

What are the characteristics of conscious sedation level 2 for pediatric dentistry?

A

decrease or eliminate anxiety; facilitate coping skills, minimally depress consciousness

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9
Q

What are the characteristics of conscious sedation level 3 for pediatric dentistry?

A
  • decrease or eliminate - anxiety
  • facilitate coping skills
  • promote sleep
  • moderately depressed consciousness
  • mimic physiologic sleep
    eyes closed most of the time
  • may or may not repsond to verbal prompts
  • mild to mod stimuli and painful stimuli elicit reflex - - - withdrawal and appropriate verbalization
  • airway may occasionally require adjustment via chin thrust
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10
Q

What are the characteristics of conscious sedation level 4 for pediatric dentistry?

A

This is considered deep sedation.
Deeply depressed level of consciousness.
Sleeplike state; eyes closed.
Does not respond to verbal command alone.
Reflex withdrawal present with no verablization when intensely stimulared.
Airway expected to require constant monitoring and frequent management.

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11
Q

What are the characteristics of conscious sedation level 5 for pediatric dentistry?

A

This is considered General anesthesia. This emilinated cognitive sensory and skeletal motor activity, some autonomic activity depressed. Unconscious and unresponsive to surgical stimuli. Partial or complete loss of protective reflexes, including the airway. Does not respond purposefully to physical and verbal command.

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12
Q

How often do you monitor HR?

A

continuous

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13
Q

How often do you monitor blood pressure?

A

every 5 min

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14
Q

How often do you monitor ECG?

A

continuous with parenteral (anyone not the mouth) techniques

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15
Q

How often do you monitor oximetry?

A

continuous

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16
Q

How often do you monitor temperature?

A

always with general anesthesia

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17
Q

How often do you monitor respiration?

A

continuous

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18
Q

How often do you monitor capnography?

A

??

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19
Q

What are the personnel recommendations for level 2 and 3 sedation?

A

two trained individuals must be present at all times - dentist and assitant must both be BCLS certified

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20
Q

What are the personnel recommendations for level 4 and 5 sedation?

A

three trained individuals must be present at all times - dentist must have GA training and one ACLS certified
- for level 5 separate qualified person to administer anesthesia

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21
Q

What are the monitoring recommendations for level 2 and 3 sedation?

A

pulse oximeter, heart rate, blood pressure

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22
Q

What are the monitoring recommendations for level 3 sedation?

A
  • precordial/pretracheal stethoscope

- capnography (desirable)

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23
Q

what is capnography?

A

the monitoring of the concentration or partial pressure of carbon dioxide (CO₂) in the respiratory gases.

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24
Q

What are the monitoring recommendations for level 4 and 5 sedation?

A
  • ECG
  • capnography
  • IV line in place
  • record every 5 min
  • temperature
  • defribrillator (keep handy)
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25
Q

What are patient instructions prior to sedation therapy?

A

Allow to have clear liquids up to 2 hours prior to anesthetic - allows for improved gatric emptying and decrease gastric pH.
Milk/solids 4-6 hours prior to anesthetic (preferably 6hrs. Larger meals 8 hrs)

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26
Q 
What is the respiratory rate of the following: 
1 yr old
3 yr old
6 yr old
12 yr old
Adult
A 
1 yr old- 25-35
3 yr old - 20-30
6 yr old- 18-25
12 yr old- 15-22
Adult- 8-15
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27
Q 
What is the heart rate of the following: 
1 yr old
3 yr old
6 yr old
12 yr old
Adult
A 
1 yr old- 100-140
3 yr old - 80-125
6 yr old- 80-120
12 yr old- 75-110
Adult- 60-80
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28
Q 
What is the blood pressure of the following: 
1 yr old
3 yr old
6 yr old
12 yr old
Adult
A 
1 yr old- 90/60
3 yr old - 100/60
6 yr old- 110/60
12 yr old- 110/65
Adult- 125/80
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29
Q

What are the general rules for oral sedation?

A
  • strict supervision of children
  • adequate time to act
  • quiet environment
  • protective reflexes intact
  • ASA I & II patients
  • post operative instructions preoperatively
  • knowledge of drug side effects
  • emergency equipment availability
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30
Q

What are commonly used drugs for sedative - hypnotics?

A

sedative-hypnotics
benzodiazepine
non-benzos

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31
Q

What are sedatives?

A

decreases anxiety and activity

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32
Q

what are hypnotics?

A

produces drowsiness to facilitate or maintain sleep

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33
Q

Name 5 examples of benxos that are sedative hyonotics.

A 
midazolam (versed)
aprazolam (xanax)
diazepam (valium)
triazolam (halcion)
lorazepam (ativan)
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34
Q

what is the brand name of midazolam?

A

versed

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35
Q

what is the brand name of aprazolam?

A

xanax

36
Q

what is the brand name of diazepam?

A

valium

37
Q

what is the brand name of triazolam?

A

halcion

38
Q

what is the brand name of lorazepam?

A

ativan

39
Q

Name 4 examples of non-benzos that are sedative hyonotics.

A

hydroxyzine (vistaril or atarax)
promethazine (phenergan)
zolpidem- ambien
zolepion- sonata

40
Q

what are benzodiazepines used for?

A
  • hypnosis
  • sedation
  • anxiolysis
  • amnesia
  • anticonvulsant
  • muscle relaxation
41
Q

What benzodiazepine has the greatest receptor affinity?

A

lorazepam (ativan)

42
Q

What receptors do benzodiazepines bind to?

A

Alpha 1 and alpha 2 GABA receptors

43
Q

Binding to alpha 1 GABA a receptor results in what?

A

sedation, antegrade amnesia, anticonvulsant properties

44
Q

Binding to alpha 2 GABA a receptor results in what?

A

anxiolysis, muscle relaxation

45
Q

Describe the basic benzo mechanism.

A

The benzo binds to the gamma receptor of GABA receptor increasing its affintiy to the receptor on CNS which triggers gating of the chloride channel causing hyperpolarization of the cell making the cell resistant to excitation.

Built in limitations of sedation but can still see depressed respirations where it can be life threatening but its difficult to achieve and does not happen frequently.

46
Q

Where are the greatest benzo receptor density found?

A

olfactory bulb, cerebral cortex, cerebellum, hippocampus, substantia nigra, inferior colliculus

47
Q

Where are benzo receptors also found?

A

striatum, lower brain stem, spinal cord (prob respponsible for the muscle relaxation properties seen)

48
Q

What is the onset and duration dependent on for benzodiazepines?

A

lipid solubility

49
Q

What are the affects of benzos on the CNS?

A

Reduces metabolic central requirement for O2 (CMRO2) and cerebral blood flow (CBF)
Increases the seizure threshold of local anesthetic

50
Q

What are the affects of benzos on the respiratory system?

A
  • respiratory depression (greater with midazolam)

- apnea increases with old age, debilitating disease, opioids

51
Q

What are the affects of benzos on the cardiovascular system?

A

decrease in SVR

decrease in BP

52
Q

What are the specific actions of Diazepam (valium)?

A 
sedation
hypnosis
anxiolysis
anticonvulsant
muscle relaxation
antegrade amnesia
coronary vasodilation
53
Q

Where is diazepam metabolized? What is the half life of diazepam? What is the onset of action? What is the duration of action? What is the peak levels in plasma? Active metabolites?

A
  • metabolized in the liver
  • t1/2 20-80 hours
  • onset of action: rapid (20 min)
  • duration of action: long (2-3 hrs)
  • peak plasma levels: 2 hrs
  • YES
54
Q

What is the dosage for diazepam (valium) in adults? children? What are the available tabs for diazepam? What are the available solutions for diazepam?

A

Adults: 5-10 mg (but start off with 5mg)
Children 0.2-0.3 mg/kg

Tabs: 2,5,10 mg
Oral Solution: 1,5 mg/ml
Inj solution: 5 mg/ml

55
Q

How long can diazepam’s affect last for?

A

Can last up to 24 hours

56
Q

what are active metabolites?

A

an active metabolite results when a drug is metabolzied by the body into a modified form which continues to produce effects in the body.

57
Q

What are the 3 active metabolites of diazepam? What causes an increase in clearance of the metabolites?

A

Temazepam
Oxazepam
Desmethyldiazepam

Smoking increases clearance because induction of the enzymes that metabolize diazepam.

58
Q

Where is midazolam (versed) metabolized? What is the half life of midazolam? What is the onset of action? What is the duration of action? What is the peak levels in plasma? Active metabolites?

A
  • metabolized in the liver
  • t1/2 1.5-5.5 hours
  • onset of action: rapid (20 min)
  • duration of action: short
  • peak plasma levels: 1.3 hr
  • YES
59
Q

Why is midazolam (versed) better used as an oral or IV sedation?

A

Much shorter duration

60
Q

What is the dosage for midazolam (versed) in adults? children? What are the available solutions for midazolam?

A

Adults: 5-10 mg
Children 0.2-0.75 mg/kg

Oral Solution: 0.5 mg/ml (no tabs in U.S.)
Inj solution: 1, 5 mg/ml

61
Q

What is the active metabolites of midazolam (versed)?

A

1-hydroxymidazolam

62
Q

How much more potent is midazolam to diazepam? Does smoking increase clearance of midazolam?

A

3-6x

YES

63
Q

Where is triazolam (halcion) metabolized? What is the half life of triazolam? What is the onset of action? What is the duration of action? What is the peak levels in plasma? Active metabolites?

A
  • metabolized in the liver
  • t1/2 1.5-5.5 hours
  • onset of action: rapid (20 min)
  • duration of action: short
  • peak plasma levels: 1.3 hr
  • NO
64
Q

What is the dosage for triazolam (halcion) in adults? children? What are the available tabs for triazolam? What are the available solutions for triazolam?

A

Adult: 0.25-0.5 mg; 0.25 mg QHS (every night at bedtime)

Pediatric - safety in children less than 12 yrs not well established.

Tabs: 0.125, 0.25mg

There is no solution, thus no IV.

65
Q

When do you typically see overdoses with triazolam (halcion)?

A

usually at 4x the therapeutic dose

66
Q

What is a significant side effect of halcion?

A

antegrade amnesia

- amnesia post op

67
Q

Where is alprazolam (xanax) metabolized? What is the half life of alprazolam (xanax) ? What is the onset of action? What is the duration of action? What is the peak levels in plasma?
Active metabolites?

A
  • metabolized in the liver
  • t1/2 12-15 hours
  • onset of action: intermediate
  • duration of action: short
  • peak plasma levels: 1-2 hr
  • NO
68
Q

What is the dosage for alprazolam (xanax) in adults? children? What are the available tabs for alprazolam (xanax)? What are the available solutions for alprazolam?

A

Adults: 1-2mg ; 0.25-0.5 mg tid
Children: safety in children less than 12 yrs not well established

Tabs: 0.25,0.5, 1, 2mg
No solutions.

69
Q

Where is lorazepam (ativan) metabolized? What is the half life of lorazepam (ativan) ? What is the onset of action? What is the duration of action? What is the peak levels in plasma?
Active metabolites?

A
  • metabolized in the liver
  • t1/2 10-20 hours
  • onset of action: intermediate
  • duration of action: short
  • peak plasma levels: 2 hr
  • NO
70
Q

What is the dosage for lorazepam (ativan) in adults? children? What are the available tabs for lorazepam (ativan)? What are the available solutions for lorazepam (ativan)?

A

Adult: 2-4 mg, 0.5-1.0 mg tid
Pediatric: 0.05mg/kg; 0.09 mg/kg produced ataxia w/o increased sedation; safety in children less than 12 yrs not well established

Tabs:0.5, 1, 2 mg
Oral solution: 2mg/ml

71
Q

What are the benzos recommended for oral sedation?

A

Triazolam (halcion)

Midazolam (versed) use this because of its shorter duration of action and increase effects of hypnosis and anti-anxiety

72
Q

Fastest rank of peak plasma levels (hours).

A
  1. Midazolam (versed) 0.5
  2. Triazolam (halcion) 1.3
  3. Alprozolam (xanax) 1-2
  4. Diazepam (valium) 2
  5. Lorazepam (ativan) 2
73
Q

Which benzos have no active metabolites?

A

alprazolam (xanax)
lorazepam (ativan)
midazolam (versed)
triazolam (halcion)

74
Q

History of choral hydrate

A

caused a lot of nausea

moved away from drug in adults and peds currently

75
Q

Where is hydroxyzine metabolized? What is the half life of hydroxyzine? What is the onset of action? What is the duration of action?
Active metabolites?

A
  • metabolized in the liver
  • t1/2 20-25 hours
  • onset of action: 15-30 min
  • duration of action: 3-4 hr
  • metabolite: cetirizine
76
Q

What is the mechanism of action of hydroxyzine (atarax)?

A

Non-selective antagonist of central and peripheral histamine H1 receptor

77
Q

What are the adverse side effects of hydroxyzine (atarax)

A

drowsiness

dry mouth

78
Q

What is the dosage for hydroxyzine in adults? children? What are the available tabs for hydroxyzine? What are the available solutions for hydroxyzine?

A

Adult: 50-100 mg (note that most adults at 100 mg probably are not sedated enough at this dose)
Pediatric 0.6-1.1 mg/kg

Tabs: 10,25,50,100 mg oral solution 2mg/ml, inj 25 mg/ml

79
Q

What is hydroxyzine classified as?

A

Antihistamine

80
Q

What is promethazine (phenegran) used as?

A
  • phenothiazine dervative
  • antihistamine
  • sedation
  • antiemetic
  • antimotion sickness
  • anticholinergic
  • local anesthetic
  • negligable CV and respiratory effects
81
Q

What are the adverse effects of promethazine (phenegran)?

A

dry mouth
blurred vision
extrapyramidal reactions (uncontrollable movements with extremities)

82
Q

What is the dosage for promethazine in adults? children? What are the available tabs for promethazine? What are the available solutions for promethazine?

A

Adult: 25-50 mg
Children: 1.1 mg/kg

Tabs: 12.5,25,50 mg
Oral solutionL 1.5, 5 mg/ml
Inj 25, 50 mg/ml

83
Q

Where is zolpidem (ambien) metabolized? What is the half life of zolpidem? What is the onset of action? What is the duration of action? What is the peak plasma level?
Active metabolites?

A
  • metabolized in the liver via oxidation
  • t1/2 2.5 hours
  • onset of action: fast
  • duration of action: 8 hr
  • peak plasma levels: 1 hour
  • NO
84
Q

What is the dosage for zolpidem in adults? children? What are the available tabs for zolpidem? What are the available solutions for zolpidem?

A

Adults: 5-20 mg (note 20 mg is way too high, don’t go by brand dose)
Peds: ??

Tabs: 5, 10 mg
No solution

85
Q

Where is zaleplon (sonata) metabolized? What is the half life of zaleplon? What is the onset of action? What is the duration of action? What is the peak plasma level?
Active metabolites?

A
  • metabolized in the liver via oxidation
  • t1/2 1 hours
  • onset of action: fast
  • duration of action: 4 hr
  • peak plasma levels: 1 hour
  • NO
  • ACTS AS BENZO RECEPTOR
86
Q

What is the dosage for zaleplon (sonata) in adults? children? What are the available tabs for zaleplon? What are the available solutions for zaleplon?

A

Adult: 5-20 mg
Pediatric:?

Tab: 5,10 mg
No solution

87
Q 
List the adult and ped dose for the following meds: 
diazepam
midazolam
lorazepam
hydroxyzine
promethazine
A 
Diazepam 
A: 10-15 mg (max 30mg)
C: 0.2-0.3mg/kg 
midazolam
A: 5-10 mg (max 20mg)
C: 0.2-0.4 mg/kg
lorazepam
A: 0.5-2mg
C:0.05mg/kg
hydroxyzine
A:25-100 mg
C:0.6-1.1 mg/kg
promethazine
A: 25-50 mg
C:1.1mg/kg

Sedation (4 decks)

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