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Dr Mistry > Week 11- Sedation and GA > Flashcards

Week 11- Sedation and GA Flashcards

1
Q

What are sedative techniques?

A
  • Nitrous Oxide sedation
  • Oral sedation
  • IV sedation
  • GA
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2
Q

What are characteristics of Nitrous oxide sedation?

A
  • Relative analgesia
  • Form of conscious sedation
  • Safe and effective when administered properly
  • Common in paeds dentistry
  • Anxiolytic and mild analgesic
  • Pt is relaxed but responsive
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3
Q

What % nitrous oxide is generally used?

A

50%

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4
Q

What is stage 1, plane 1, 2 and 3 sedation, stage 2, stage 3 and stage 4?

A
  • Stage 1, plane 1: moderate sedation and analgesia.
  • Stage 1, plane 2: dissociation sedation and analgesia
  • Stage 1, plane 3: total analgesia
  • Stage 2: excitement or delerium
  • Stage 3: surgical anaesthesia
  • Stage 4: respiratory paralysis
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5
Q

What are characteristics of stage 1, plane 1 RA?

A
  • Inc pain threshold
  • Reflexes and vital intact
  • Relaxed and less fearful
  • Paraesthesia
  • Conscious communication
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6
Q

What are charactersitics of stage 1, plane 2 RA?

A
  • Similar to plane 1 but further relaxation
  • Possible reduced blink rate
  • Reduced pharyngeal reflex
  • Laryngeal reflex intact
  • ‘Floating’ feeling
  • Can maintain open mouth
  • Mild flushing
  • Some amnesia
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7
Q

What stage/plane is it no longer considered RA?

A

Beyond stage 1, plane 2 it’s no longer RA.

There is no gradual transition from one plane to next.

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8
Q

What are characteristics of stage 1: plane 3 sedation?

A
  • May not be able to maintain open mouth
  • May be sleep, sweaty, nauseous
  • May not respond verbally or to pain
  • Reduced refexes
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9
Q

What are characteristics of stage 2 nitrous oxide sedation?

A
  • Undesirable stage for dental surgery
  • Excitement, struggling
  • Reflexes reduced significantly
  • Increased BP, HR
  • Irregular respiratory rate
  • Pupils dilated
  • Could have loss of consciousness
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10
Q

What is stage 3: surgical anaesthesia?

A

General anaesthesia?

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11
Q

What can stage 4: respiratory paralysis cause?

A

Respiratory arrest > death

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12
Q

What are properties of nitrous oxide?

A
  • Non-irritating, colourless, sweet-smelling
  • Non-flammable
  • Quick onset and recovery- low blood-gas solubility coefficient (0.47)
  • Solubility ratio is 15-36x that of nitrogen
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13
Q

When is primary saturation of blood and brain with nitrous oxide?

A

Within 3-5 minutes

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14
Q

Describe importance of solubility ratio of nitrous oxide?

A

Nitrous oxide has a low blood solubility (0.47), leading to a quick onset and recovery.

Solubility ratio of N2O is 15-35x that of nitrogen. N2O diffuses more rapidly into closed spaces than nitrogen can diffuse out, leading to increased gas volume and pressure within closed spaces.

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15
Q

How is N2O metabolised?

A
  • No biotransformation in body
  • Excreted unchanged via lungs at similar rate to absorption
  • Small amount excreted thorugh skin, sweat glands, urine, intenstinal gas
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16
Q

What are effects of NO on CNS?

A
  • NO likely directly acts on opioid receptors.
  • Acts on RAS- controls emotions
  • Analgesia
  • Euphoria and depressant
  • Amnesia
  • Anxiolytic/sedative
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17
Q

What are effects of NO on CVS?

A
  • Heart: no direct effects at therapeutic dose. Reduced HR in 1st stage of anaesthesia could be due to peripheral vasodilation or anxiolytic effect
  • Vasculature: peripheral vasodilation- flushing or sweating
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18
Q

What are the respiratory effects of NO?

A
  • No direct effect
  • Non-irritating
  • Caution with emphysema/COPD
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19
Q

What are GIT effects of NO?

A

Nausea, vertigo

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20
Q

What are effects of NO on reflexes?

A

Progressive reduction in reflexes with increasing concentration?

21
Q

What are effects of NO on haemopoietic system?

A

Transient bone marrow depression (long term exposure)

22
Q

What are NO effects on PNS?

A

Sensory neuropathy with chronic abuse

23
Q

What are NO effects on reproductive system?

A
  • Passes readily across placenta
  • Avoid in 1st trimester
24
Q

What are indications for NO?

A
  • Able to co-operate with tx
  • Fear or anxiety- mild-moderate
  • Sensitive gag reflex
  • Intolerance to long appts
25
What are contraindications for NO?
* Pre-cooperative child (\<3 yo), intellectually disabled * Uncooperative child * Children requiring extensive or very complicated tx * **Airway blockage**- common cold * Conditions with trapped gas- otitis media, bowel obstruction, brain injury, pneumothorax * Claustrophobic * Psychiatric disorders * Significantly medically compromised * Pregnancy 1st trimester * Pts at risk of N2O induced bone marrow suppression * Bleomycin therapy (chemo)- fibrosis of lungs
26
What patients are at risk of N2O induced bone marrow suppression, increased homocysteine levels or neurotoxicity?
* Hx of B12 or folate deficiency * Nutritionally compromised pts, vegetarians * Pts on H2 blockers or proton pump inhibitors * Serious illness, infection, extensive tissue damage * MTHFR deficiency
27
What are safety features of N2O?
* O2 flow of 3-10L/min * Capacity for administration of 100% O2 * Auto air intake in event of O2/gas flow supply failure
27
What are safety features of N2O?
* O2 flow of 3-10L/min * Capacity for administration of 100% O2 * Auto air intake in event of O2/gas flow supply failure
28
What are equipment guidelines for N2O?
* Safety features * One way valve to prevent re-breathing * Reservoir bag * Scavenging system of expired gases * Australian standards * Serviced/checked routinely
29
What are requirements for using N2O?
* Additional training required * Person administering must remain present at all times * Always have a chaperone * Advanced life support skills * Informed consent and post-op * Record details
30
What is required for monitoring pt during N2O sedation?
* Pulse oximeter * Check vital signs * Measure O2 saturation and HR of patients * Audible and visual alarm system
31
What is the technique for N2O sedation?
* Nasal mask according to pt size * 6L/min flow rate * Reservior bag partially inflated but not full * Titrate * Constant monitoring * Rubber dam, high volume suction * Diffusion hypoxia * Have child seated for few minutes after procedure * Post-op intructions and discharge
32
What are complications of nitrous oxide likely associated with?
* Over-sedation * Lack of monitoring * Interaction with other meds- CNS depressants, sedatives
33
What are adverse reactions of N2O?
* Nausea and vomiting (in high concentrations) * Dizziness * Hypoxia * Oversedation \> respiratory depression, loss of consciousness * N2O rapidly inflates gas-filled spaces e.g. careful in pts with otitis media * Bone marrow depression from chronic use (\>24hours)
34
What are occupational hazards with prolonged exposure to N2O?
Interference with Vit B12 synthesis causing: * Haemotological disorders * Neurological disorders
35
What are advantages of N2O?
* Non-invasive * Mild analgesic * Anxiolytic/sedative * Minimal impact on reflexes and vitals for RA * Concentration easily altered * Rapid onset and recovery
36
What are disadvantages of N2O?
* Co-operation with mask * Interference of mask with procedure * Continuous administration * Occupational hazard * Lack of potency * May still need behavioural management * Cost for practice
37
What are characteristics of oral and IV sedation?
* Minimally depressed level of consciousness * Pt can maintain airway * Respond to physical stimuli and verbal command
38
What are indications for oral sedation?
* Anxious * Co-operation required for long procedure * When parenteral routes are undesirable
39
What are contraindications for oral sedation?
* Unable to take meds orally * Med issues and interactions * Use precautions with children \>6yo
40
What are indications for IV sedation?
* Anxious * Invasive procedure of short duration
41
What are contraindications of IV sedation?
* Inability to tolerate IV access * Medical issues and interactions * Use precautions with children \<6yo
42
What are sedative agents?
* Benzos (midazolam, diazepam) * Antihistamines (promethazine, hydroxyzine) * Opioids * Ketamine * Barbiturates
43
What is GA?
* Induced state of unconsciousness * Loss of protected reflexes, including inability to independently maintain airway and respond purposefully to physical stimulation or verbal command
44
What are the objectives of GA?
* Provide safe, efficient, effective dental care * Eliminate anxiety * Reduce untoward movement and rx to dental tx * Aid in tx of mentally, physically or medically compromised pts * Eliminate pain response
45
What are indications for GA?
* Very anxious * Moderately-extremely uncooperative * Not responsive to other modes of behaviour management * Extensive surgical tx * Prompt tx of acute condition * If unable to achieve ideal tx for child in chair
46
What are contra-indications for GA?
* Medical issues where risks outweighs benefits * Pt manageable with other forms of behavious management
47
What is required for treating under GA?
* Effort to ensure there is only 1 GA * Comprehensive work up, tx planning * Definitive tx (don't place GIC's)

Dr Mistry (8 decks)

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