Pain and anxiety Flashcards
What is conscious sedation?
A technique in which the use of a drug or drugs produces a state of depression of the central
nervous system enabling treatment to be carried out, but during which verbal contact with
the patient is maintained throughout the period of sedation. The drugs and techniques used
to provide conscious sedation for dental treatment should carry a margin of safety wide
enough to render loss of consciousness unlikely.
What 3 things can someone under conscious sedation do?
- Remain conscious
- Retain protective reflexes
- Is able to understand and respond to verbal commands
What must happen if a patient is unable to respond to verbal contact when fully conscious?
An effective means of communication must be maintained.
Need to understand what their normal way of communicating is and maintain this.
What are 4 broad indications for inhalation sedation?
- Medical reasons = conditions affecting cooperation.
- Psychosocial
- Conditions aggravated by stress
- Dental
Indications for conscious sedation as a potential adjunct for patient management include patients with: (SDCEP) (5)
- dental anxiety and phobia;
- a need for prolonged or traumatic dental procedures
- medical conditions potentially aggravated by stress (IHD, hypertension, asthma, epilepsy)
- medical or behavioural conditions affecting the patient’s ability to cooperate (movement disorders and learning difficulties, spasticity disorders, parkinson’s disease)
- special care requirements
What medical reasons are indications for inhalation sedation? (4)
- Learning difficulties
- Spasticity disorders (multiple sclerosis, cerebral palsy)
- Parkinson’s
- Medical conditions aggravated by stress of dentistry - IHD, hypertension, asthma, epilepsy, psychosomatic illness, misc conditions (UC, Crohn’s disease) etc
What psychosocial reasons are indications for inhalation sedation? (4)
- Phobia and anxiety
- Gagging
- Persistent syncope
- Idiosyncrasy to LA - lack of response to LA.
What dental reasons are indications for inhalation sedation? (2)
- Difficult or unpleasant procedures, such as XLA of 8s and implants or ortho XLA.
- Traumatic procedures
What is the definition of a phobia?
An irrational and uncontrollable fear related to a specific object or situation. It is persistent despite avoidance of the provoking stimuli, affecting the patient’s lifestyle.
What can cause dental anxiety?
Environment
Surgery appearance
Staff continuity
Trauma (usually primary experience in childhood, often cumulative experiences)
Learned behaviour from parents or playground
Developmental (young and old patients, and those with learning difficulties).
Fear of criticism
What are social factors that are contraindications to sedation? (4)
- Unwilling
- Uncooperative
- Unaccompanied
- Very old
What are medical factors that are contraindications to sedation? (6)
- Severe or uncontrolled systemic disease
- Severe mental or physical handicap
- Severe psychiatric problems
- Narcolepsy
- Hypothyroidism
- Patient on many drugs –> reduced drug clearance, the use of sedatives should be avoided as coma is a risk.
What are contraindications to use of benzodiazepine? (5)
- Intracranial pathology
- COPD - leads to lower O2 saturation
- Myasthenia gravis - weakens the respiratory muscles, benzos already cause respiratory depression
- Hepatic (liver) insufficiency - can’t break down and metabolise drug properly
- Pregnancy and lactation - will pass to baby.
What are contraindications to nitrous oxide (inhalation sedation)? (3)
- Blocked nasal airway
- COPD
- Pregnancy and lactation
What are dental factors that are contraindications to sedation? (4)
- Procedure too long for sedation
- Spreading infection - airway threatening (limits LA effectiveness)
- Procedure too traumatic (GA)
- Urgency of treatment - long waits
What is important to assess before considering sedation?
- Drug history
- Allergies
- Previous exposure to sedation and GA
- Mobility
- Medical condition state (well controlled?)
What are the 6 ASA grades?
ASA I = patient with no systemic disease
ASA II = patient with mild systemic disease that does not affect lifestyle
ASA III = patient with moderate systemic disease affecting lifestyle/pt with severe systemic disease
ASA IV = patient with severe systemic diseases, threat to life constant
ASA V = not expected to survive without the operation
ASA VI = clinically brain dead, awaiting organ harvest
What is the relationship between blood pressure and fitness for treatment on the ASA scale?
ASA I = <140/<90, routine Rx
ASA II = <160/<95 recheck regularly
ASA III = <200/<105 recheck after 5 mins, refer to GMP
ASA IV = >200/>105 emergency Rx only prior to BP management
What ASA is done in primary care, and which are carried out by specialist facility
ASA I/II = primary care
ASA III+ = specialist facility
- While many ASA grade III patients will need to be referred to secondary care, some may
be treated in primary care depending on the available facilities, knowledge, skills and
experience and on the current stability of the patient’s medical condition. - ASA grade IV patients requiring dental sedation should be referred to an appropriate
secondary care facility.
What needs to be recorded as part of the assessment process to inform suitability for sedation (3) and what needs to be measured before?
- Blood pressure
- Heart rate
- Oxygen saturation (pulse oximeter)
For healthy pts (most ASA grade I and II) having inhalation sedation with nitrous oxide/oxygen, these measurements are not usually necessay
Weight, height, BMI - useful for reversal drug calculations
Can general anaesthesia be carried out in primary dental care setting?
NO
For sedation, how old is a A) child, B) young person, C) adult
A) A person under 12 years of age
B) A person aged 12-16
C) A person ager 16+
What are recognised as standard sedation techniques? (also known as ‘basic’ techniques?
- For a child, young person or adult, inhalation sedation with nitrous oxide/oxygen
and
- For a young person or adult, midazolam by any route (intravenous, oral or transmucosal)
What are recognised as advanced sedation techniques? (alternative techniques)
For a child, young person or adult:
- certain drugs used for sedation (e.g. ketamine, propofol, sevoflurane);
- combinations of drugs used for sedation (e.g. opioid plus midazolam, midazolam plus propofol, sevoflurane plus nitrous oxide/oxygen)
- combined routed of administration (e.g. oral plus intravenous)
and
- for a child, midazolam by any route
Who is in the dental sedation team?
Clinical staff involved directly in sedation, including dedicated sedationist (dental professional, medical practitioner, anaesthetist), operator-sedationist and dental sedation nurse (or other sedation assistant)
What are the responsibilities of the referring practitioner?
To make a thorough clinical assessment of the pt as possible.
To explore alternative methods of pain and anxiety management
To assess whether referral is absolutely necessary to enable delivery of dental care
To provide appropriate clinical info about the pt with the referral, as far as pt compliance allows.
To provide the pt with information about why they are being referred, likely options for care and what to expect.
To provide preventive oral health advice and to encourage the pt to seek continuing dental care
To record details of the referral
What other anxiety managements techniques are there apart from conscious sedation?
Non-pharmalogical behaviour management
–> (cognitive behavioural therapy (CBT), distraction, guided imagery, hypnosis, play therapy)
General anaesthesia
What adaptations in treatment plans an protocols could occur? examples
- a reduced drug dose for frail and/or older patients, with titration of smaller increments at increased time intervals;
- pre-operative recording of physiological data or intra-oral examination may not be
possible for some children or patients with special care requirements; - non-verbal means of communication;
- the use of a dedicated sedationist.
What information should be provided to the patient and carer before the sedation?
Info on what to expect before, during and after sedation, including clear instructions about fasting and escort requirements.
Include details of
- escort responsibilities
- post-operative risks and possible
complications
- analgesia
- aftercare advice (including about the patient’s usual
medication)
- restrictions on post-sedation activities
- contact details for the care provider
- out-of-hours contact details for emergency advice and services.
What are pre-operative instructions for conscious sedation?
Food (light meal 2 hours prior) (check SDCEP?)
No alcohol
Medicine taken normally
Escort must be present
Consent, both verbal and written
What are post-op instructions for conscious sedation?
Escort (give all advices to them in written and verbal formats)
Try not to go home on public transport (London hard)
Diving, cycling and machinery risk
Return to work protocol (advise time off work)
Medication taken normally
Safety, practicality and pharmacology (not to be a sole carer for child or relative) (not signing any documents in next 24 hours)
What is the guidance of fasting before conscious sedation?
For conscious sedation, provide advice about whether or not to fast based on an
individual assessment of the patient and the nature of the sedation and dental
procedure.
(Expert opinion; Low quality evidence)
Following careful consideration of all factors for each patient:
* if there are no indications for fasting, advise a patient who is to receive conscious
sedation that they can eat and drink on the day of their appointment, avoiding
alcoholic drinks and large meals.
* if there is judged to be a significant risk of aspiration, or another indication, consider
fasting prior to sedation. The 2-4-6 fasting rule is a recognised fasting regime used in
anaesthesiaa
- Record in the patient’s notes the advice provided to the patient about eating and drinking prior to sedation and the justification for this advice.
- Confirm and record food and fluid intake on the day of sedation.
Do adult patients receiving inhalation sedation with nitrous oxide/oxygen require an escort?
According to SDCEP, they do not usually require and escort.
For inhalation sedation with nitrous oxide/oxygen it is standard practice that an adult does not require an escort unless there are other indications such as mobility issues.
It is the sedationist’s
responsibility to assess the patient and advise if an escort is required.
Do children require an escort after inhalation sedation?
Children and young people under 16 years of age do require an escort for inhalation sedation with nitrous oxide/oxygen.
What are the requirements for an escort?
For anything other than inhalation sedation, ensure the escort is aware of the need for a responsible adult to remain with the patient as a minimum for the rest of the day.
- for those sedated later in day, escort may need to remain overnight
- role of escort may be carried out by more than one person e.g. pt returning to care home or who requires two carers
- responsibility of escort extends to ensure pt takes normal prescribed medication and carries out the routines required to manage any concurrent chronic health condition
- wherever possible, pt and escort should travel home by private care or taxi rather than public transport.
- if either pt or escort appears to be unwilling or unable to comply with these requirements, conscious sedation must not be administered
What should be included in pt’s records from the pre-sedation assessment?
Full medical history (including prescribed and non-prescribed drugs and any known allergies)
Blood pressure
BMI
Heart rate and oxygen saturation
Potential airway difficulties
ASA status
Dental history
Social history
Conscious sedation and general anaesthetic history
Dental treatment plan
Assessment of anxiety and any tools used
The selected conscious sedation technique and justification
Any individual patient requirements
Provision of pre- and post operative written instructions provided before treatment, including advice given on fasting
Written consent for conscious sedation and dental treatment
What should be included in the pt’s notes for the visit for dental tx under conscious sedation?
- Presence of a responsible adult escort
- Time that food and drink were last consumed
- Arrangements for suitable post-operative transport and supervision
- Compliance with the pre-treatment instructions
- Presence of written consent for the procedure and reconfirmation
- Any changes in the recorded medical history or medication
What should be included in the treatment procedure notes?
- Dose, route and time(s) or administration of drugs
- Site of cannulation and/or attempted cannulation (for intravenous, oral and transmucosal sedation)
- Details of clinical and electromechanical monitoring (i.e. pre-operative, after drug titration, intra-operative and post-operative measurements, and in particular any significant events)
- Personnel present in surgery
- Patients reaction, sedation score and success of sedation
- Dental treatment provided
What should be included in the recovery notes?
- Monitoring - appropriate details of observations and measurements throughout
- Pre-discharge assessment by sedationist - appropriate discharge criteria met
- Written post-operative instructions given and explained to patient and escort
- Removal of cannula (for intravenous, oral and transmucosal sedation)
- Time of discharge
What can be prescribed as an oral premedication for anxiolysis?
A low dose of benzodiazepine can be prescribed as oral premedication for anxiolysis to assist with sleep the night before treatment or to aid an anxious patient’s journey under close supervision to the treatment facility.
Can oral premedication be used as a standalone method for anxiety management?
Yes, it can be used as the standalone method without being followed by sedation at treatment.
What do higher doses of benzodiazepines count as?
oral sedation (not just premedication)
Can a premedicated patient give valid consent?
NO!
So consent must be achieved in pre-sedation appointment whilst patient has capacity.
Does a patient that is premedicated need to be escorted?
YES!
Advise the patient that when premedicated they will need to be escorted to and from the treatment facility and should not drive
When do you use standard sedation techniques compared to advanced?
Use standard sedation techniques, unless there are clear indications to do otherwise.
What is inhalation sedation?
Titrated dose of nitrous oxide with oxygen is standard inhalation sedation
It is a mild sedative agent that safely and effectively manages pain and anxiety during dental treatment for adults and children.
Always min of 30% oxygen used.
The success of the technique depends on appropriate titration of nitrous oxide
to the individual patient’s response and is supported by behaviour management techniques.
Dedicated inhalation sedation machines will not allow hypoxic levels of sedation.
Can inhalation sedation be used before intravenous sedation?
YES
Note that inhalation sedation with nitrous oxide/oxygen may be used before intravenous sedation to facilitate cannulation but, to remain a standard technique, would be discontinued prior to
administration of midazolam.
What does the success of intravenous sedation rely on?
Successful intravenous sedation with a wide margin of safety is dependent on titration of the drug dose according to the individual patient’s response and therefore the use of fixed doses or bolus techniques is unacceptable.
What is standard intravenous sedation technique?
Use of titrated doe of midazolam
Note that intravenous sedation of children with midazolam is considered an advanced technique
When do you remove the canula after IV sedation?
Maintain intravenous access by way of an indwelling cannula until the patient is fit for discharge
Oral premedication, topical local anaesthesia or inhalation sedation may facilitate cannulation for some patients.
How can midazolam be administered? (3)
Intravenous
Oral
Transmucosal (intranasal)
What technique can be used for patients with extreme needle-phobia?
Oral and transmucosal sedation with midazolam
Can oral and transmucosal sedation with midazolam be an advanced technqiue?
These techniques are also occasionally used in combination with other sedation techniques, in which case this would be considered advanced sedation.
Note that oral and transmucosal sedation of children are considered to be advanced techniques.
How does oral and transmucosal sedation with midazolam compare to sedation from titrated IV midazolam?
The state of conscious sedation resulting from oral or transmucosal sedation might be
comparable to that produced by the intravenous administration of drugs, but it is less controlled
and therefore less predictable.
Why do pts taking oral and transmucosal sedation with midazolam need to be cannulated still?
Cannulate asap due to the less predictable nature of either oral and transmucosal sedation. It is just in case the administration of a reversal agent is required.
Where do you administer oral and transmucosal sedation with midazolam?
At the sedation facility
When should advanced techniques be used?
Only use an advanced technique if the clinical needs of the patient are not suited to
sedation using a standard technique.
What do advanced techniques include?
- The use of certain drugs
- Combination of drugs and/or combined routes of administration
Why are advanced techniques more risky?
Drug combinations have less
predictable effects than single drugs, and some anaesthetic drugs and infusions used for sedation have narrower therapeutic indices.
Consequently, advanced sedation techniques are likely to
have reduced margins of safety, potentially increasing the risk of adverse events.
What must be checked staff wise before doing an advanced technique?
If using an advanced sedation technique, ensure that its use is justified and record the
justification in the patient’s records.
Ensure that all members of the dental sedation team are specifically trained and
experienced in the use of advanced techniques for the patient groups being treated
Ensure that the facilities, knowledge and skills required for the prompt recognition and
immediate management of sedation-related complications and medical emergencies are
in place
When do you monitor the patient?
Pre-operative stage until discharge criteria are met
What are the clinical signs that should be monitored during sedation?
- Check level of consciousness/depth of sedation
- Airway patency
- Respiration (rate and depth)
- Skin colour
- Capillary refill
- Pulse rate, rhythm and volume
What should be monitored for all pts with inhalation sedation?
For all patients having inhalation sedation with nitrous oxide/oxygen, monitor the
patient’s clinical signs*.
* Additionally, non-invasive blood pressure (NIBP) monitoring may be indicated for some patients, for example, those with significant degrees of cardiovascular disease.
What should be monitored for adults and young people having an sedation (other than inhalation)?
For adults and young people having any sedation technique other than inhalation
sedation with nitrous oxide/oxygen, monitor as a minimum, the patient’s clinical signs*, oxygen saturation using pulse oximetry, and blood pressure.
What should be monitored for children having an sedation (other than inhalation)?
For children having any sedation technique other than inhalation sedation with nitrous
oxide/oxygen, monitor the patient’s clinical signs*, oxygen saturation using pulse
oximetry and, unless likely to prevent completion of the procedure, blood pressure.
When may you need to monitor ECG or capnography?
Monitoring by electrocardiogram (ECG) or capnography is not currently required for conscious
sedation for dental treatment.5
However, such additional monitoring may be appropriate for ASA grade III and IV patients.
What is the preferred conscious sedation technique for children?
Inhalation sedation with nitrous oxide/oxygen is the only standard technique for children.
A brief trial of nitrous oxide/oxygen at the assessment appointment may be helpful for
the psychological preparation of some children.
What are the preferred conscious sedation techniques for young people?
Use inhalation sedation with nitrous oxide/oxygen or intravenous
midazolam as the preferred techniques, unless these standard techniques are judged to be unsuitable for the patient and clinical need.
- Oral and transmucosal sedation using midazolam, while also considered standard
techniques for young people, are only appropriate in a minority of cases (e.g. for
patients with special care requirements or needle phobia).
Whose decision and responsibility is it to discharge the patient?
The decision to discharge a patient following any type of sedation is the responsibility
of the sedationist, although aspects of the discharge process may be delegated to a suitably trained member of the clinical team.
What is the discharge criteria?
The patient is orientated in time, place and person.
- Vital signs are stable and within normal limits for the patient. Respiratory status is not
compromised. - Pain and discomfort have been addressed.
- Where relevant, haemostasis has been achieved.
- The cannula, where inserted, has been removed.
- The responsible escort is present and arrangements have been made for supervision as
advised by the sedationist. - Written and verbal post-operative instructions appropriate for both the sedation technique and the dental treatment have been given to the patient and escort.
What are recognised training providers for sedation?
Validated training is training delivered by a recognised provider
(UK universities, Health Education England, NHS Education for Scotland, the Wales Deanery,
the Northern Ireland Medical and Dental Training Agency or Schools of Anaesthesia) or that is accredited through the dental faculties of the UK surgical royal colleges.
What critical incidents during sedation should be reported?
Choking, vomiting, over-sedation, emergency use of flumazenil or naloxone and medical emergencies.
What are the ideal sedative properties?
Anxiolysis - reduce patient anxiety
Analgesic - reduce pt pain
No effect on CVS or respiratory system
Not metabolised
Easy and quick to change level of relaxation
Reversible
No contraindictions with other drugs
Cheap
Long shelf life
What effects does benzodiazepine have?
Anxiolysis - first effect is at low doses, and high anxiety increases dose requirement.
Sedation - decreased response to constant stimulus
Anticonvulsant - sedative, and they terminate or prevent fits
Amnesia - IV administration gives anterograde amnesia. Most intense for 20-30 mins. Unpredictable duration.
What does anterograde amnesia mean?
Inability to form new memories.
Can benzodiazepines analgesics?
No, but they can effect the pain experience. They are not an analgesic, but they influence response to pain.
What is the pharmacology behind benzodiazepine?
BZD acts on receptors to enhance the effect of GABA (anticonvulsant and sedation)
BZD mimics effects of glycine (muscle relaxation and anxiolysis)
Where are GABA receptors and Glycine receptors found?
GABA receptors in the cerebral cortex
Glycine receptors in brainstem and spinal cord
What are the contraindications of of benzodiazepines?
Suspected allergy to BZD
Patient is epileptic
Patient dependant on BZD
Drug interactions
- Angina (Verapamil, Diltiazem)
- Anti-retroviral
- Anti-fungal (fluconazole)
- Anti-bacterial (erythromycin)
What drug interactions do benzodiazepines have?
Angina - verapamil, diltiazem
Anti-retroviral
Anti-fungal (fluconazole)
Anti-bacterial (erythromycin)
What are the side effects of benzodiazepines?
Depression of respiratory system and CNS
Muscle relaxation
Decreases cerebral response to CO2 - enhanced in patients with chronic bronchitis (COPD contraindication)
Cardiovascular effects
= HR increases via baroreceptor reflex
= Reduced blood pressure by decrease in vascular resistance
Drug interactions
- Increased respiratory depression with CNS depressant drugs
- Synergistic interaction with opioids
- Pharmacokinetic interactions (ketoconazole, erythromycin and midazolam)
Sexual fantasy
- reported in both male and female patients
- dose related (midazolam > 0.1 mg/kg)
What are negative effects of BZD?
Tolerance to oral BZD
Dependence
- long term BZD causes addiction, with withdrawal experienced
- Dependence activated by acute administration
- Acute withdrawal caused by BZD antagonists
