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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
Q

What are contraindications for NO?

A
  • 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
Q

What patients are at risk of N2O induced bone marrow suppression, increased homocysteine levels or neurotoxicity?

A
  • 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
Q

What are safety features of N2O?

A
  • O2 flow of 3-10L/min
  • Capacity for administration of 100% O2
  • Auto air intake in event of O2/gas flow supply failure
27
Q

What are safety features of N2O?

A
  • O2 flow of 3-10L/min
  • Capacity for administration of 100% O2
  • Auto air intake in event of O2/gas flow supply failure
28
Q

What are equipment guidelines for N2O?

A
  • Safety features
  • One way valve to prevent re-breathing
  • Reservoir bag
  • Scavenging system of expired gases
  • Australian standards
  • Serviced/checked routinely
29
Q

What are requirements for using N2O?

A
  • 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
Q

What is required for monitoring pt during N2O sedation?

A
  • Pulse oximeter
  • Check vital signs
  • Measure O2 saturation and HR of patients
  • Audible and visual alarm system
31
Q

What is the technique for N2O sedation?

A
  • 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
Q

What are complications of nitrous oxide likely associated with?

A
  • Over-sedation
  • Lack of monitoring
  • Interaction with other meds- CNS depressants, sedatives
33
Q

What are adverse reactions of N2O?

A
  • 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
Q

What are occupational hazards with prolonged exposure to N2O?

A

Interference with Vit B12 synthesis causing:

  • Haemotological disorders
  • Neurological disorders
35
Q

What are advantages of N2O?

A
  • Non-invasive
  • Mild analgesic
  • Anxiolytic/sedative
  • Minimal impact on reflexes and vitals for RA
  • Concentration easily altered
  • Rapid onset and recovery
36
Q

What are disadvantages of N2O?

A
  • 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
Q

What are characteristics of oral and IV sedation?

A
  • Minimally depressed level of consciousness
  • Pt can maintain airway
  • Respond to physical stimuli and verbal command
38
Q

What are indications for oral sedation?

A
  • Anxious
  • Co-operation required for long procedure
  • When parenteral routes are undesirable
39
Q

What are contraindications for oral sedation?

A
  • Unable to take meds orally
  • Med issues and interactions
  • Use precautions with children >6yo
40
Q

What are indications for IV sedation?

A
  • Anxious
  • Invasive procedure of short duration
41
Q

What are contraindications of IV sedation?

A
  • Inability to tolerate IV access
  • Medical issues and interactions
  • Use precautions with children <6yo
42
Q

What are sedative agents?

A
  • Benzos (midazolam, diazepam)
  • Antihistamines (promethazine, hydroxyzine)
  • Opioids
  • Ketamine
  • Barbiturates
43
Q

What is GA?

A
  • Induced state of unconsciousness
  • Loss of protected reflexes, including inability to independently maintain airway and respond purposefully to physical stimulation or verbal command
44
Q

What are the objectives of GA?

A
  • 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
Q

What are indications for GA?

A
  • 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
Q

What are contra-indications for GA?

A
  • Medical issues where risks outweighs benefits
  • Pt manageable with other forms of behavious management
47
Q

What is required for treating under GA?

A
  • 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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