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SA Flashcards

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1
Q

Define conscious sedation and general anaesthesia

A
  • reducing or stopping physiological responses without loss of consciousness, cooperation or protective reflexes. Used to ease discomfort/ stress/pain/anxiety
    -depresses the CNS
    -verbal contact remains

-GA= absence of sensation, without the ability to maintain physiology function such as breathing and protective reflexes. Carried out in hospital setting

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2
Q

What drugs is used for conscious IV sedation and its dose. What is its reverse drug

A

-midazolam 5mg/5ml
0.5mg - sedated, 25g anaesthetised
-flumazenil - 200ug initially, 100ug/min, 1mg max

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3
Q

Indications/ Types of patients that benefit from sedation

A

*Moderate dental anxiety/ phobias
*Children - Used more routinely as part of behavioural management (eg. if uncooperative)
*Medically compromised patients - Stress precipitates conditions e.g. asthma, angina, hypertension
*Special needs patients -poor cooperation with mild learning disability, cerebral palsy, Parkinson’s etc.
*Gag and swallow reflex
*Persistent fainting
*Traumatic dental procedures (MOS, implants)

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4
Q

Contraindications for IV sedation

A

-Unwilling/uncooperative
-Unaccompanied
-Very old - liver and kidney affects metabolism
-Children<12 -Sensitive to dosage with young people. Restless in chair (opt for GA)
-Severe or uncontrolled systemic disease- e.g. recent MI, COPD
-Hepatic or renal insufficiency -Won’t metabolise the drug= DO NOT give sedation
-Pregnancy and breastfeeding - inhalation is fine
-severe needle phobia
-methotrexate

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5
Q

Contraindications for RA sedation

A

poor nasal airway
Claustrophobic patients
Middle Ear/Sinus Infection (nitrous oxide can go into air filled cavities and increase pressure in these areas)
Certain types of occular surgery
Behavioural problems/Personality disorders
URTI
Severe anxiety
Pregnancy
Methotrexate
Bleomycin therapy

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6
Q

What affect does methotrexate have with nitrous oxide

A

The drug Causes depletion of folate. With nitrous oxide can cause dangerous low levels

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7
Q

Why bleomycin sulphate is contraindicated with nitrous oxide

A
  • anti-neoplastic therapy
  • due to the increased incidence of pulmonary fibrosis and other lung diseases.
  • predisposed to respiratory failure following exposure to high concentrations of oxygen over 25%.
    -Since use of 100% oxygen is part of the standard sedation procedure (in both the initial and recovery phases) there is an increased risk of possible problems in these patients.
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8
Q

Where does metabolism and excretion of IV/ inhalation drugs occur

A

liver metabolism
kidney excretion

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9
Q

Types of drugs that increase risk of respiratory depression and drop in BP with midazolam

A

-Antihypertensives= HUGE DROP IN BP
-ritonavir (antiviral) = extreme risk of respiratory depression

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10
Q

What is included in patient assessment before sedation (RA and IV)

A

-suitability (why it is needed)
-assess pulse, BP, respiratory rate, BMI, oxygen saturation

Pre-procedural checklist:
-staff and equipment check
-Patient check: fitness (MH), written consent, understanding of procedure, escort home, light meal before hand, no alcohol prior (synergistic effect)

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11
Q

What is the ASA classification system

A

-American Society of Anaesthesiologists
-Classification based on physical status
-Allocation of patients to grades according to:
o Medical status
o Operative/anaesthetic risk
-Estimation of fitness for sedation or GA
- I to V

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12
Q

What is ASA I. What is their BP

A

-patient without systemic disease; a normally healthy patient
-minimal anxiety
<60 years old
< 140 / 90 BP

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13
Q

What is ASA II

A

-MILD systemic disease - well-controlled (asthma, non-insulin diabetes, anaemia)
-very phobic, overweight (BMI>30), pregnant, special needs, drug allergy, smoker, alcoholic
-OR any healthy patient >60 years old (slower physiology)
< 160 / 95 BP

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14
Q

What conditions fit in the classification of ASA III.

A

-MODERATE systemic disease; which limits function but is not incapacitating
-poorly controlled insulin diabetes, epilepsy, angina, COPD, asthma etc
-Chronic bronchitis or emphysema
-Congestive heart failure or thyroid disease
< 200 / 115 BP
BMI>40

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15
Q

What is ASA IV

A

INCAPACITATING SYSTEMIC DISEASE; which is a constant threat of life
- sepsis, ongoing cardiac ischemia
-<3 months Post MI or CVA or TIA or stent
-COAD or CHF requiring O2 therapy
-Uncontrolled dysrhythmias
-Blood pressure > 200 / 115

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16
Q

What is ASA V and VI

A

5=moribund patient not expected to survive 24 hours unless treated
6= brain dead

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17
Q

Why someone with insulin dependant diabetes (type I) is at risk during sedation

A

-likely will go hypo as cannot eat the morning of sedation however will still take insulin = glucose stores will be depleted rapidly and pt becomes hypo – difficult to tell this is happening when sedated

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18
Q

Which ASA classifications (I-V) are suitable for sedation in a GDP

A

*ASA I = Suitable for sedation in GDP
*ASA II= Suitable for sedation in GDP; with appropriate precautions
*ASA III= Increased risk > usually refer to hospital
*ASA IV / V = Life-threatening disease = must be treated in hospital (should be by an anaeshtetist)

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19
Q

Indications for cannulation in dentistry

A

1.IV drug administration
-Prophylaxis (antibiotic/steroid cover)
-Medical Emergency
2. IV sedation

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20
Q

Sites for cannulation. Pros and cons for each

A
  1. Dorsal veins of the hand
    -Easily visible, superficial veins. No vital structures
  2. Antecubital fossa (basilic, cephalic, median cubital veins)
    -Large veins
    -Danger of brachial artery & median nerve
    -Problems with joint movement
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21
Q

Step by step technique of cannulation

A

-Draw up 0.9% saline into 5ml syringe
-Select 22g venous cannulae & check its working order
-Select an appropriate vein
-Apply tourniquet, 10cm above cannulation site
-Wait for vein to become engorged (hand clenching, tapping vein)
-Wipe surface
-Tense skin & insert cannula at an angle of 10-15 degrees through skin and into the vein
-A 1st flash-back of blood at white cap end indicates the cannula has entered the vein
-Withdraw the metal needle slightly (0.5cm) so can see needle end and flashback
-Advance cannula up to its hub
-Remove tourniquet
-Remove metal insertion needle & place end cap – be quick
-Secure cannula with tape & administer 2-5ml saline into injection port (if lump appears then cannula is subcutaneous > so remove & resite)

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22
Q

Complications that can arise during cannulation and how to overcome

A

1.Difficult Veins
=Be patient
2.Extra-venous Cannulation
-Pain on cannulation
-Formation of subcutaneous lump
=Resite cannula
3.Intra-arterial Injection
-Significant pain, bright red pulsatile blood
=remove needle, apply pressure (+/- refer)
4.Haematoma Formation
-Avoid multiple venepuncture
-Avoid penetrating opposite wall of vein
=apply Pressure after cannula removed
5. Pain in arm, fingers, back of hand

23
Q

IV sedation procedure

A

*Cannulation
*Record arterial oxygen saturation – good to have >97%
*Drug titration – midazolam 5mg/5ml
o 1mg injected slowly
o Wait 1 minute
o 1mg every minute thereafter
o Slow titration against to patient effect
-Flush with saline
-Commence dental treatment

24
Q

Signs of sedation

A

-Slurring and slowing of speech
-Relaxed appearance
-Delayed response to commands
-Ptosis – drooping of upper eyelids
-Willingness to undergo treatment
-Feeling warm and tingly

25
Q

Things to check before discharging patient after IV sedation

A

-Monitor arterial oxygen saturation for at least 1 hour after last increment
-Discharge: at least 1 hour after, with escort, can walk in straight line, satisfactory BP and oxygen saturation
-POIG: no drinking, driving, signing legal docs for 24 hrs

26
Q

Complications of IV sedation

A

-Respiratory depression: due to reduced arterial oxygen saturation
-Over-sedation
-Disinhibition – react in complete opposite way to expected= Uncooperative/ aggressive/ violent
-Medical emergencies (epilepsy seizure won’t occur)
-Allergy to midazolam

27
Q

What to do if oxygen saturation drops during sedation

A

=over sedation, respiratory depression. Signs=nausea, headache, vomitting, loss of consciousness
-Get patient to take deep breaths, tilt chin back and opening airway.
-Supplement oxygen can be given - 3l/min
-Or if this does not work use flumazenil (reversal)

28
Q

Differential diagnosis of loss of consciousness

A

-Vasovagal attack (faint)
-Over-sedation
-Cardiac arrest – no pulse/ not breathing
-Hypo-glycaemia – if pt has insulin but no breakfast – MH IMPORTANT
-Adrenal crisis
-Cerebrovascular Accident - stroke
-Epilepsy

29
Q

Signs and symptoms of vasovagal syncope

A

=Vasodilation in vessels going toward skeletal muscles – BP drops. Not enough Cardiac output to maintain blood to brain
-Cause - anxiety, pain, fatigue, fasting

Signs and symtpoms:
-Nausea, pallor
-Sweating
-Pulse - weak/thready. rapid (conscious) then sudden slow (unconscious)
-Sudden loss of consciousness
-Fits & cyanosis

30
Q

Management of vasovagal syncope

A

-Supine + raise legs (ALLOWS BLOOD TO RUSH BACK TO BRAIN)
-Glucose drink & reassurance
-Oxygen (10 litres per min)
-Monitor breathing & pulse
-If recovery not rapid (within 1-2 mins), re-consider diagnosis

31
Q

Signs and symptoms of hypoglycaemia

A

-Cause: poorly controlled diabetes, Missed meal but has insulin, Infection, Fever

Warning (adrenergic signs):
-Irritable/uncooperative = less compliant with dental treatment
-Hunger, dry mouth
-tremor
-palpitations, sweating

Established signs:
-Drowsiness/ disorientation
-confusion
-aggression
-slurred speech
-Gradual loss of consciousness

32
Q

Management of hypoglycaemia

A

-Confirm glucose level (< 4 mmol/l)
-If Conscious = glucose/dextrose drink or tablets/gel
-If Unconscious = glucagon 1mg IM. Takes 10-15 mins to work + oral glucose once conscious
-Oxygen & monitor (glu >5mmol/l)
-Paramedics to check pt afterwards – pt will feel very sleepy afterwards

33
Q

Differential diagnosis of acute chest pain. And breathing problems

A

-Stable angina
-Acute coronary syndromes (unstable angina and MI) – persists with GTN
-GORD
-Pleuritic pain
-Pulmonary embolism
-Musculoskeletal
-Panic attack

-Asthma attack
-Anaphylaxis

34
Q

Causes of stable angina, signs and symtpoms

A

-Reversible Myocardial ischemia -coronary artery blocked with atheroma, not enough O2 gets through when heart is stressed

Signs:
-Severe retrosternal pain (behind sternum) on exercising or stress
-May radiate down left arm and jaw
-Regular pulse

35
Q

Management of stable angina attack

A

-Glyceryl trinitrate (GTN) spray (0.4mg) – this treats it, unlike MI
-Sublingual – if swallowed, will go to liver and 90% will be broken down ASAP
-Repeatevery 5 mins, up to 3 times
-Oxygen (10 litres per min)
-Monitor = if no relief, consider possibility of MI

36
Q

Signs and symptoms of acute coronary syndromes (unstable angina and MI)

A

*Causes
-Fissure of atheromatous plaque=Coronary occlusion
=Sudden ischaemia =Irreversible damage to heart muscle

*Signs
-Crushing retrosternal pain
-Death-like appearance
-Breathless, vomiting, distress
-Weak, irregular pulse, loss of consciousness, potential cardiac arrest

37
Q

Management of unstable angina or MI

A

-Comfortable position
-Oxygen
-Call paramedics
-GTN Spray
-Nitrous oxide 50% with oxygen 50% (if available) – same analgesic effect as MORPHINE & it causes vasodilation
-Aspirin 300mg orally
-Monitor for cardiac arrest

38
Q

Signs and symptoms of asthma

A

Exacerbated by anxiety, Stress, Exercise, Infection, Allergy, cold air, pollen
-Breathlessness
-Cannot form sentences
-High RR>25
-Wheezing on expiration/ cough
-Tachycardia >110
-Accessory muscles of respiration

Worrying sings= bradycardia, cyanosis, low RR, confusion, exhaustion, decreased level of concsiousness

39
Q

Management of asthma

A

-Sit upright
-2 puffs Salbutamol inhaler +/- spacer (0.1mg/puff) every 10 mins up to 10 puffs
-Oxygen (10 litres per min)
-Call paramedics (if no improvement or status asthmaticus)

40
Q

Cause of anaphylaxis. What type of hypersensitivity is it

A

-Immediate type I hypersensitivity reaction
-Exposure to antigen in a sensitised individual

-Antigen > attaches to IgE antibody on eosinophils & mast cells > degranulation & release of mediators
=Bronchospasm, vasodilatation, oedema, hypotension

41
Q

Signs and symptoms of anaphylaxis

A

-Facial flushing
-Oedema
-Acute breathlessness (bronchospasm)
-Severe hypotension, vasodilation
-Weak/ impalpable pulse
-Loss of consciousness
-rash that blanches

42
Q

Management of anaphylaxis

A

-Supine and raise legs
-Adrenaline 1:1000 0.5ml (0.5mg) IM – NEVER IV
-If required repeat after 5 mins
-Oxygen
-Call paramedics

43
Q

List guidelines for conscious sedation

A

IACSD 2015
SDCEP 2017

44
Q

Indications for GA in dentistry

A

Routine extractions:
* Where LA/sedation has failed
* Acute infection
* Multiple primary extraction in very young patients
* (usually Not for orthodontic extractions)

Complex extractions – surgical extractions, full clearance
Routine dental treatment in special cases -Severe learning difficulties or movement issues

45
Q

Safety features incorporated into the inhalation sedation equipment

A

-colour coding (NO is blue, Oxygen is white)
-oxygen fail safe - nitrous oxide automatically cut off if oxygen run out
- oxygen flush
-reservoir bag- Ensures patient is breathing correctly – easy to visualize
-minimum oxygen percentage of 30%
-Air entrainment valve: If gases run out the valve will open and allow patient to breath air
-gas pressure dials
-active scavenging system - vacuum to limit gas released into atmosphere
-one way valve
-emergency cut off

46
Q

How often is RA equipment serviced

A

6 monthly/yearly service
Daily checks before use

47
Q

Explain inhalation sedation

A

-A semi-hypnotic technique of conscious sedation in which nitrous oxide and oxygen produce physiological changes to alleviate anxiety so that the patient can co-operate sufficiently to allow dental treatment to take place
-The patient should remain conscious and co-operative through out with all vital reflexes intact. Should be able to communicate throughout

48
Q

Advantages of inhalation sedation over IV

A

-Rapid onset: 2-3 minutes for clinical signs
-Rapid peak action: 3-5 minutes
-Depth of sedation easily regulated
-Duration of sedation flexible
-Rapid recovery: 3-5 minutes on 100% oxygen
-Moderate analgesia effect
-No injection
-Few side effects
-Drug not metabolised
-No adverse effects on the liver, kidneys, brain, cardiovascular system or respiratory systems

49
Q

Disadvantages of RA

A

Cost of equipment
Space occupying equipment
Not a potent agent
A degree of co-operation is necessary
Possibility of chronic exposure

50
Q

Pre-op instructions for RA

A

-A light meal 2 to 4 hours before appointment
-Children must be accompanied by a responsible adult and be supervised for rest of day
-Transport home in car or taxi
-Children should not ride bikes, drive vehicles or operate machinery for the rest of the day

51
Q

Step by step technique of RA administration

A

-Set dial to 100% oxygen
-Settle patient in the chair
-Turn on oxygen at a rate of 4-6L/min
-Ask patient to place nasal hood on nose
-Ensure good seal of hood
-Adjust flow rate
-Make sure breathing through nose
-Continual reassurance: explain they are in warm sunny place with tingly hands and feet
-Turn dial to 90% oxygen
-After 1 minute turn dial to 80% oxygen
-Continue until suitable level of sedation
-If bag over inflated – reduce flow rate and vise versa
-Commence treatment
-When treatment complete switch to 100% oxygen
-Breath for 2- 3 minutes (to prevent Diffusion Hypoxia)
-Remove nasal hood & sit patient up, check not dizzy
-Discharge home with post-op instructions

52
Q

Causes of failure of RA technique

A

Nasal obstruction
Patient mouth breathing
Inefficient seal of nasal hood
Extreme anxiety
Fault in machine

53
Q

Management of RA over-sedation

A

Reduce nitrous oxide by 5 to 10%
Reassure patient
Monitor patient
Continue or postpone treatment

Stage 4 TMD/SA (2 decks)

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