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Stage 4 TMD/SA > SA > Flashcards

SA Flashcards

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 (3mg total usually over 3 mins)
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 as safer)
-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
-severe needle phobia
-methotrexate
-high BMI (if >36) or sleep apnoea- done in hospital)
-no escort available

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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 (if essential then do 2nd trimester and 30% max)
Methotrexate
Bleomycin therapy
COPD

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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 (only for IV), light meal before hand, no alcohol or rec drugs prior (synergistic effect), if had previous sedation (can help indicate how much to give)

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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

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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 to make sure all in system
-Commence dental treatment

24
Q

Why administer midazolam in increments

A

1mg over 1 minute (sometimes 0.5 mg if history of fast effect)
So you can monitor the patient while it takes effect as it take 40 seconds to get to brain

25
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

26
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

27
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

28
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.
-If <94%: Supplement oxygen can be given - 3l/min
-If <90% then use faster flow of oxygen in mask
-Or if this does not work use flumazenil (reversal)

29
Q

Can you use sedation if pregnant or breastfeeding

A

-No IV if pregnant: can affect the baby
-No RA if pregnant as can affect baby. If essential then in 2nd trimester as in 1st it can cause developmental issues and 3rd it can cause preterm birth
-RA fine if breastfeeding as out of system immediately
-Avoid IV if breastfeeding, but can do if for 24 hours using formula or use pumped milk
-can’t be is same room as someone getting RA

30
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

31
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

32
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

33
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

34
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

35
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

36
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

37
Q

Management of stable angina attack

A

-Glyceryl trinitrate (GTN) spray (400ug) – 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

38
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

39
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

40
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

41
Q

Management of asthma

A

-Sit upright
-2 puffs Salbutamol inhaler +/- spacer (100ug/puff) every 10 mins up to 10 puffs
-Oxygen (10 litres per min)
-Call paramedics (if no improvement or status asthmaticus)

42
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

43
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

44
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

45
Q

List guidelines for conscious sedation

A

IACSD 2015
SDCEP 2017

46
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

47
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- if pt feeling over sedated
-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

48
Q

How often is RA equipment serviced

A

6 monthly/yearly service
Daily checks before use- check bag inflates, correct flow rate, tubes connected properly

49
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

50
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
-Don’t need an escort

51
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

52
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
-Adults don’t need escort
-Transport home in car or taxi
-Children should not ride bikes, drive vehicles or operate machinery for the rest of the day
-If have a cold, ask if can breath through nose fine
-Pregnant mums or other children not allowed in room

53
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

54
Q

Causes of failure of RA technique

A

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

55
Q

Management of RA over-sedation

A

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

56
Q

Options if needle has large needle phobia and is very anxious

A

Ask what in particular about needles they don’t like- the sight, the feel etc and can work around it
-RA + IV
-nasal sedation + IV
-Oral pre-med (temazapam)
-Surface anaesthesia 1hr pre
-GA

Stage 4 TMD/SA (2 decks)

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