Dr. Yarascavitch - Toronto Academy of Dentistry

Transcription

Dr. Yarascavitch - Toronto Academy of Dentistry
14-11-24
David After Dentist
Relaxed, But Not Asleep: How to use
Nitrous Oxide or Oral Benzodiazepines
for Effective Minimal Sedation
Dr. Carilynne Yarascavitch
BSc DDS MSc (Dental Anaes) Dip ADBA
c.yarascavitch@dentistry.utoronto.ca
Dangers in the Dental Office
Purpose
§ 
§ 
§ 
§ 
Refresher for those practicing sedation
Primer for those interested
Technique Tips
Regulatory Landscape
What kind of sedation?
Focus
§  Minimal Sedation
§  Adults
§  RCDSO Compliance
–  Framework for this session
§  “Practice Ready”
–  Practice tips to be prepared for patients
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Confidence is the feeling you have
before you understand the situation.
Play safe.
Objectives
§  At the end of this session, attendees will be
able to:
1.  Identify the clinical signs which distinguish
minimal from moderate sedation.
2.  Select patients, drugs, and doses suitable for
the goal of minimal sedation.
3.  Establish policies and practices in their office
which comply with RCDSO regulations.
What is “Sedation” ?
§  Sedation
–  Suppression of arousal and behaviour
–  Decrease in activity
§  Anxiolysis
–  Ability to decrease anxiety
§  Amnesia
–  Ability to impair memory
§  Hypnosis
–  Ability to produce drowsiness and facilitate
onset and maintenance of sleep
Objective 1
Identify the clinical signs which
distinguish minimal from
moderate sedation.
Continuum Depth of Sedation
Clinical
Effect
Minimal ðModerate ðDeep ðGA
Sedation
Anxiolysis
Amnesia
Hypnosis
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Minimal vs Moderate Sedation
Minimal vs Moderate Sedation
§  Minimal sedation
§  Moderate sedation
– Sedation, anxiolysis
•  amnesia
– Comfortable and relaxed
– May experience natural sleep
– Conscious at all times
– Respond purposefully to
verbal and tactile simulation
RCDSO Standards of Practice
Overview
§  Use of Sedation and General
Anaesthesia In Dental Practice
(Approved by Council June 2012)
§  Minimal standards for the use of
sedation
RCDSO Standards of Practice
Part I – Conscious Sedation
Conscious Sedation
“…a minimally to moderately depressed level
of consciousness that retains the patient’s
ability to independently and continuously
maintain an airway and respond
appropriately to physical stimulation and
verbal command.”
Minimal Sedation
Moderate Sedation
“…responds normally to tactile
stimulation and verbal commands.
Although cognitive function and
coordination may be modestly
impaired, ventilatory and
cardiovascular functions are
unaffected.”
“…responses purposefully to verbal
commands, either alone or by light
tactile stimulation. No interventions
are required to maintain a patient
airway and spontaneous ventilation is
adequate. Cardiovascular function is
usually maintained.”
– Sedation, anxiolysis
•  amnesia, MILD hypnosis
– Comfortable and relaxed
– May be drowsy
– Conscious at all times
– Respond purposefully to repeated
verbal and tactile stimulation
Guidelines to Standards of Practice
§  Older “Guidelines”: Definitions of sedation
combine route of administration with depth
– “Oral conscious sedation”
§  2012 “Standards of Practice”: RCDSO
revisions demphasize route of administration
and emphasize depth (clinical effect)
independent of route of administration
– “Minimal, Moderate, Deep”
RCDSO Standards of Practice
§  If we define level of sedation by clinical
effect, does route of administration matter?
–  Yes.
–  Route matters for facility permits and
provider registration because the RCDSO
makes assumptions about sedation depth
based on
•  the route you use**
•  the doses you provide**
**more on this later
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How do I know if I am doing minimal or
moderate?
1)  Clinically by assessing the patients level
of consciousness using response to
voice/touch
–  Immediate – minimal
–  Repeated – moderate
2)  Artificially by route as defined by our
RCDSO regulator*
–  Multiple oral drugs
–  IV = moderate
RCDSO Appendix III
Characteristics of the Levels of Sedation
MINIMAL
SEDATION
MODERATE
SEDATION
DEEP
SEDATION
GENERAL
ANAESTHESIA
CONSCIOUSNESS
Maintained
Maintained
Reduced
Unconscious
RESPONSIVENESS
To either
verbal or
tactile
May require one
or both verbal
and tactile
Response to
repeated or
painful stimuli
Unrouseable,
even to pain
AIRWAY
Maintained
No intervention
required
Intervention
Intervention
may be required usually required
PROTECTIVE
REFLEXES
Intact
Intact
Partial loss
Assume absent
SPONTANEOUS
VENTILATION
Unaffected
Adequate
May be
inadequate
May be
impaired
CARDIOVASCULAR
FUNCTION
Unaffected
Usually
maintained
Usually
maintained
May be
impaired
REQUIRED
MONITORING
Basic
Increased
Advanced
advanced
**more on this later
How do they respond?
Verbal Indicators of Depth of Sedation
Differential Diagnosis
Characteristics of the Levels of Sedation
MINIMAL
SEDATION
MODERATE
SEDATION
DEEP
SEDATION
GENERAL
ANAESTHESIA
HOW DO THEY
RESPOND?
Voice OR
Touch?
Voice AND
touch?
REPEATED
voice and touch
or PAIN?
NO
RESPONSE
AIRWAY
No change
NO SUPPORT
required
SUPPORT
required:
Head tilt, chin
lift
Intervention
required
BREATHING
No change
SOMETIMES
Slower, smaller
breaths
USUALLY
Slower, smaller
breaths
Slowest,
smallest or NO
breaths
CIRCULATION
No change
Small changes
Moderate
changes
Big changes
PATIENT
MONITORING
Basic
Increased
EXPERT
EXPERT
Levels of Sedation
Scenario
Effect
§ 
§ 
§ 
§ 
§ 
§ 
§ 
Immediate answers
Speech is clear
Speech makes sense
Delayed answers
Nonsensical responses
Incoherent speech
No response
Levels of Sedation
Clinically Legally
69 yo F 50 kg •  Responds to light
ASA II
touch
Triazolam
•  No snoring
0.125 mg
•  RR10, HR 80
BP 120/80
Minimal
Minimal
69 yo F 50 kg •  Responds to
ASA II
voice
Midazolam
•  RR8, HR 70
1 mg IV
BP 110/72
Minimal
Moderate
Scenario
Effect
35 yo F 50 kg •  No response to
ASA II
voice, but
Triazolam
responds if
0.5 mg
touched
•  Snoring sound
35 yo F 50 kg •  Groans if pinched
ASA II
•  Snoring when you
Triazolam
lift chin, no sound
0.5 mg
if you don’t
Clinically Legally
Moderate
Moderate
Deep
!
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What depth of Sedation?
What depth of Sedation?
§  18 yo F 72 kg ASA II
§  Triazolam 0.375 mg
§  Pre-op VS: BP 128/68, HR 79, RR 12
§  25 yo F 90 kg ASA II
§  Triazolam 0.5 mg
§  Pre-op VS: BP 132/80, HR 78, RR 12
§ 
§ 
§ 
§ 
§ 
Tap lightly on the shoulder for verbal response
Respond normally to your questions
Light snoring when not stimulated
Relaxed breathing
BP 130/70, HR 75, RR 12
§ 
§ 
§ 
§ 
§ 
Responds when you touch and call their name
Response is slow
Speech is slurred but answers may sense
Loud snoring when not stimulated
BP 120/80, HR 70, RR 8
§  Moderate Sedation
§  Minimal Sedation
What depth of Sedation?
What depth of Sedation?
§  38 yo F 90 kg ASA II
§  Triazolam 0.5 mg
§  Pre-op VS: BP 120/72, HR 68, RR 12
§  57 yo F 72 kg ASA II
§  Triazolam 0.25 mg
§  Pre-op VS: BP 120/80, HR 70, RR 10
§ 
§ 
§ 
§ 
Pinching shoulder causes movement
Heavy snoring unless chin is lifted
Belly is tense and moves strangely without chin lift
BP 110/60, HR 72, RR 9
§ 
§ 
§ 
§ 
Responds when you call their name
Response is normal with clear speech
Quiet breathing
BP 120/80, HR 70, RR 10
§  Deep Sedation
§  Minimal Sedation
What depth of Sedation?
§  62 yo F 90 kg ASA II
§  Triazolam 0.5 mg
§  Pre-op VS: BP 120/72, HR 68, RR 12
§ 
§ 
§ 
§ 
No response to name, no response with jaw thrust
No breath sounds unless jaw is thrusted upward
Relaxed belly that doesn’t appear to be moving much
BP 90/60, HR 90, RR 6
Objective 2
Select patients, drugs, and
doses suitable for the goal of
minimal sedation.
§  General Anaesthesia
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RCDSO Standards of Practice
General Standards
§  Sedation techniques
– “are to be used only when indicated, as an
adjunct to appropriate non-pharmacological
means of patient management” p.2
Patient Selection
Indication for Sedation
RCDSO Standards of Practice
Professional Responsibilities
§  Fear or Anxiety
§  Poor Cooperation
§  “Adequate, clearly recorded current
medical history” (#4, p.2)
– present and past illnesses
– hospital admissions
– current medications
– non-prescription drugs
– herbal supplements
– allergies
–  Mentally Challenged
–  Cognitively Impaired
–  Motor Dysfunction
–  Gag Reflex
§  Extensive Procedure
§  Document it!
RCDSO Standards of Practice
Professional Responsibilities
RCDSO Standards of Practice
Appendix I
§  “Adequate, clearly recorded current
medical history” (#4, p.2)
§  “Core medical history”
– Functional inquiry*
– Physician consult for medically
compromised patients
– Reviewed for changes at each sedation
appointment
– Must elicit the core medical information to
enable the dentist to assign the correct
ASA Classification
– Should be system-based review of past
and current health status (see RCDSO’s
sample medical history questionnaire)
– Supplemented with questions relevant to
the use of sedation
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Functional Inquiry
Functional Inquiry
§  Investigates potential concerns from the
medical history.
§  Your functional inquiry should include a review of
systems affected, and notations on any
investigations.
§  The goal is to ask questions which help you to assess
severity and stability, in order to form an impression
of the effect of systemic disease on the patient’s
health and potential impact on treatment.
§  What is/are the diagnosis/diagnoses?
Functional Inquiry
Review of Systems
General Review of Systems
Important for any disease process
§  CNS – central nervous system: epilepsy, stroke, TIA
§  CVS – cardiovascular: hypertension, coronary artery
disease
§  RESP – respiratory: asthma, COPD
§  DERM – dermatological: eczema
§  ENDO – endocrine: diabetes, thyroid
§  GI – gastrointestinal: liver, HEPATIC
§  GU – genitourinary: kidney, RENAL
§  HEME – hematological: bleeding disorders, anemia
§  MSK – musculoskeletal: joint replacement, arthritis, osteoporosis
§  PSYCH – psychological: depression, bipolar disorder, anxiety disorder
§  SH – modifiable lifestyle factors: smoking, alcohol, recreational drugs
§  Precise medical condition
–  Estimated date of diagnosis
§  How is this condition managed?
–  Medications? Diet? Surgery?
–  No intervention (observation only)?
§  Follow-up medical care
–  Does the patient see their MD or specialist for this
condition?
–  How often?
–  Last seen?
–  What was MD’s last recommendation?
General Review of Systems
Important for any disease process
RCDSO Standards of Practice
Professional Responsibilities
§  Symptoms patient experiences
–  Does the patient have symptoms?
–  What are the symptoms?, When do they occur?,
–  When did they last occur?, What about the time
before last?
§  “A determination of the patient’s
American Society of Anesthesiologists
(ASA) Physical Status Classification as
well as consideration of any other
factors that may after his/her
suitability for sedation must be made
prior to its administration.” (#5, p.2)
•  Asking for both most recent and the previous time allows
better estimation of frequency of events, which can help
determine stability.
§  Has this condition ever required hospitalization?
§  Effect on daily life
–  Can the patient engage in normal activities or do they
have to reduce or change activities because of their
disease?
–  Estimate date of diagnosis or initial presentation
§  What underlying body systems does it affect?
–  Review the body system for sign/symptoms of disease
§  Do you need more information?
–  Gather investigations such as chairside tests e.g. blood
glucose, medical letters
§  What is your impression of the severity/stability?
–  Ask questions to determine effects on the body systems
and disease progression, limitations in daily function, and
changes in quality of life
– #1 other factor to consider: Sleep Apnea
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ASA Physical Status
Classification System
I
II
III
IV
V
E
A normal healthy patient A patient with mild systemic disease A patient with severe systemic disease A patient with severe systemic disease that is a
constant threat to life A moribund patient who is not expected to survive
without the operation A declared brain-dead patient whose organs are
being removed for donor purposes
ASA Status: CAD
ASA Status: Asthma
§  Uses puffer daily, last asthma attack 2 years ago
–  ASA II
§  Active wheezing with expiration, difficulty
breathing
–  ASA IV
§  Uses puffer daily, last asthma attack 1 week ago,
FEV1 consistently < 80% baseline
–  ASA III
RCDSO Standards of Practice
Appendix I
§  HTN, obese, severe chest pain at rest yesterday,
extreme SOB with minimal exertion 2 days ago
–  ASA IV
§  HTN, obese, SOB climbing 3 stairs, takes breaks
–  ASA III
§  HTN, 20 pack-year smoker, runs daily
–  ASA II
§  “Core Physical Examination”
Basic Physical Exam
Heart Rate
Basic Physical Exam
Blood Pressure
§  Heart Rate = # beats/min
For a patient without a pre-existing diagnosis:
§  Normal Resting HR (Adults)
–  60 to 100 bpm
§  Bradycardia
–  < 60 bpm
§  Tachycardia
–  > 100 bpm
– Current basic physical examination
– General appearance, noting abnormalities
– Taking and recording of vital signs i.e.
heart rate and blood pressure
– Appropriate airway assessment
–  Normal Blood Pressure
•  120/80
–  Prehypertension
•  120-139/80-89
–  Hypertension
•  >140/90
For a patient diagnosed with hypertension, targets:
–  <140/90
–  <130/80 for Diabetics, Renal disease
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Basic Physical Exam
Respiratory Rate
§  Respiratory Rate = # breaths/min
§  Normal Respiratory Rate (Adults)
–  8-12 breaths/min
§  Tachypnea
–  > 12 breaths/min
§  Bradypnea
–  < 8 breaths/min
§  Respiratory Arrest
Functional Inquiry Example 1
50 year-old M for periodontal treatment. Appears healthy
and well-nourished, Ht 176 cm, Wt 70 kg BMI=22.6
(healthy wt). Dentally anxious (4/5). BP 110/70, HR 76.
§  CVS: HTN (Diagnosed 2004)
§  ROS: Treated with medication Zestoretic, pt compliant with
medication
§  Pt denies SOB, CP, SOA, palpitations, TIA/Stroke. Daily exercise
30 min run 3x/wk.
§  INV: MD letter March 2013 “well controlled”
§  IMP: Mild, stable HTN
§  ASA: II
–  0 breaths/min
Functional Inquiry Example 2
Functional Inquiry Example 2
45 year old F prosthodontic needs, anxious regarding dental
treatment (3/5). Ht is 155 cm, Wt 70 kg, BMI=29.1
(overweight). Appears healthy/active. BP 140/75 HR 98.
45 year old F prosthodontic needs, anxious regarding dental
treatment (3/5). Ht is 155 cm, Wt 70 kg, BMI=29.1
(overweight). Appears healthy/active. BP 140/75 HR 98.
§  ENDO: DM2 (Diagnosed 15 yrs ago)
§  ROS: Meds: Metformin and Glyburide, pt does not always
remember to take. Hospitalized 1x 10 yrs ago hypoglycemic attack
with seizure, no sequelae; last hypoglycemic episode 3 months
ago “felt dizzy”, took oral carbohydrate, “felt fine after”, no
episodes since. Complications: retinopathy, numbness in feet,
followed by TGH endocrinologist Dr. Barry q3 months.
§  INV: Blood sugar ranges 9-12 mmol/L; HbA1c 10.4, MD reports
“poorly controlled” (MD letter Dec 13)
§  IMP: Pt has complications – mod severity; Pt has hypoglycemic
episodes and poor blood sugar control - stability questionable.
§  CVS: HTN and hyperlipidemia (Dx approximately June 2012)
§  ROS: Treated with Coversyl and Atorvastatin, SOB with heavy
exercise, denies angina, palpitations, SOA, TIA/stroke, no
hospitalizations. Can walk 2 flights stairs without stopping.
§  INV: MD letter Dec 13 BP 144/84 “poor control”
§  IMP: Target BP for diabetes should be <130/80; pt has
inadequate risk reduction for MI/Stroke.
Functional Inquiry
§  Core Functional Inquiry for Sedation
§  Respiratory System
§  Cardiovascular System
§  AIRWAY
§  Summary IMP: Poorly controlled DM2 and HTN with
questionable stability
§  ASA II +? ASA III?
Functional Inquiry
“Airway”
2 Must-ask Questions:
1.  Are the nares patent?
2.  Any diagnosis of sleep apnea?
1 “Maybe” Question:
3.  Malampatti view
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UPPER AIRWAY ANATOMY
Functional Inquiry
“Airway”
§  In the conscious state,
–  Tonic and reflex inspiratory activity in the
genioglossus keeps the tongue away from the
posterior pharyngeal wall
–  Tonic activity in the levator palati, tensor palati,
palatopharyngeus and palatoglossus prevents the soft
palate from falling back against the posterior pharynx
Obstruction by the tongue and epiglottis.
STOP-BANG Questionnaire (Chung et al, 2008)
Obstructive Sleep Apnea Screening
Please answer the following questions to the best of your ability.
S
Do you snore loudly (louder than talking or loud enough to hear
through a closed door?)
T
Do you often feel tired, fatigued, or sleepy during the daytime?
O
Has anyone observed you stop breathing during your sleep?
P
Do you have or are you being treated for high blood pressure?
Yes No
For Doctor’s Use.
B
BMI >35 kg/m2
A
Age >50 years
N
Neck circumference >40 cm
G
Gender M
2 STOP + 2 BANG – high risk sleep apnea - DO NOT TREAT
2 STOP + 1 BANG – possible sleep apnea
. Circulation 2000;102:I-22-I-59
2 STOP + 0 BANG – low risk sleep apnea
Copyright © American Heart Association, Inc. All rights reserved.
Mallampati Classification
Malampati Classification
§  Popular predictor for difficult airway management (modified by Samsoon & Young 1987) is a §  Basis: visibility of oral & pharyngeal structures with paEent siFng in upright posiEon, mouth fully opened, tongue fully extended, without phonaEon §  I & II: Easy §  III & IV Difficult §  I & II = easy airway §  III & IV = difficult 10
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Functional Inquiry
“Airway”
2 Must-ask Questions:
1.  Are the nares patent?
– 
Delivery of nitrous oxide, supplemental oxygen
2.  Any diagnosis of sleep apnea?
– 
– 
Relative contraindication to minimal sedation
Nitrous oxide best choice
1 “Maybe” Question:
3.  Malampatti view
• 
Drug Selection
Class IV may be difficult to rescue from over-sedation
How do I know if I am doing minimal or
moderate?
RCDSO Standards of Practice
Overview
1)  Clinically by assessing the patients level
of consciousness using response to
voice/touch
–  Immediate – minimal
–  Repeated – moderate
§  Specific standards for particular
modalities
2)  Artificially by route as defined by our
RCDSO regulator*
–  Multiple oral drugs
–  IV = moderate
*more on this now
1. 
2. 
3. 
4. 
5. 
6. 
N2O
Oral single sedative drug
Oral single sedative drug + N2O
Oral multiple sedative drugs (+/- N2O)
Parenteral (IV)
Deep Sedation
What modalities are considered by the
RCDSO to produce minimal sedation?
What modalities are considered are by the
RCDSO to produce moderate sedation?
1.  Administration of nitrous oxide and
oxygen ALONE
2.  Oral administration of a SINGLE
sedative drug
3. Combination of 1 & 2
1.  Oral administration of multiple
sedative drugs
2.  Administration of a sedative drug (s)
by any parenteral route:
–  IF minimal sedation is your intent
–  AND symptoms reflect an effect of
minimal sedation
• 
• 
• 
• 
• 
Intravenous
Intramuscular
Subcutaneous
Submucosal
Intranasal
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Sedation Medications
Route/Modality Onset
Sedation Medications
Titrate
Duration
Reversal
Titrate
Duration
Reversal
Inhalational
Rapid
Rapid
Controlled
Easy
Route/Modality Onset
Inhalational
Rapid
Rapid
Controlled
Easy
Oral
Slow
No
Prolonged
Hard
Oral
Slow
No
Prolonged
Hard
Intravenous
Rapid
Rapid
Prolonged
Possible
Intravenous
Rapid
Rapid
Prolonged
Possible
N2O Properties
§  Sedation
§  Analgesia
Nitrous Oxide
N2O Pharmacokinetics
N2O Pharmacodynamics
§  Blood gas coefficent Pb/g-0.47
§  MAC = 104
–  Low solubility in blood
–  Rapid uptake
–  Rapid elimination
§  0.004% biotransformation in GI tract
–  Excreted almost entirely unchanged
–  Low potency
•  At 104% Nitrous Oxide, 50% of patients
experience general anaesthesisa
•  Between 20-50% Nitrous Oxide, patients
experience conscious sedation
§  Cardiovascular Effects
–  Weak myocardial depressant
–  Mild sympathomimetic
•  Minimal overall effect
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N2O Pharmacodynamics
N2O Contraindications
§  Respiratory Effects
§ 
§ 
§ 
§ 
§ 
§ 
–  Weak respiratory depressant (êvolume)
–  Mild sympathomimetc (érate)
•  May potentiate other agents
•  Healthy Patients: Minimal overall effect
–  Decreased central hypercapnic response (C02)
–  Decreased peripheral hypoxemic response (O2)
•  Severe COPD patients can experience
respiratory arrest
Nasopharyngeal obstruction
Severe COPD
Closed Tissue Spaces
Belomycin chemotherapy
Claustrophobia
Vitreoretinal surgery within 3 months
N2O Contraindications
N2O Contraindications
§  Nasopharyngeal obstruction
§  Bleomycin chemotherapy
–  Can you easily breathe through your nose?
–  Do you commonly get nasal congestion?
§  Severe COPD
–  Have you ever been told you should have home
oxygen?
§  Closed Tissue Spaces
–  Do you have middle ear disease?
–  Have you ever been treated with bleomycin?
•  IV, IM, or SubQ antibiotic chemotherapy
•  Lymphoma, testicular or squamous cell?
§  Claustrophobia
–  Do you get anxious in confined spaces?
§  Vitreoretinal surgery within 3 months
–  Have you had eye surgery in the past 3 months?
–  If so, what type?
–  Perfluoropropane C3F8 or Sulfurhexafloride SF6
Is this a good choice?
§  Can you minimize leaks? (maximize dose)
–  Use a rubber dam?
–  Will patient exhale through their nose not mouth?
§  Is your patient likely to enjoy?
–  Finds alcohol relaxing?
–  Misinterpret symptoms as disturbing?
Benzodiazepines
§  Procedural Considerations
–  Will the nasal hood be in the way?
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BDZ Properties
BDZ Pharmacokinetics
§  Agonists of BDZ subunit GABA receptor
§  Absorption
§ 
§ 
§ 
§ 
§ 
Anxiolysis
Sedation
Amnesia
Muscle Relaxants
Anticonvulsants
–  Delayed
–  Average of 60 to 30 minutes
–  PO and SL routes have different effect
•  PO routes have a “first pass” through the liver
before entering the systemic circulation (where
they affect the brain)
•  Happens because venous blood from the intestine
(where the drug is absorbed) enters the liver first
•  Dose reduction ~30% if given sublingual
BDZ Pharmacokinetics
BDZ Pharmacodynamics
§  Distribution
§  Systemic effects negligible
–  First to VRG (Brain) then Muscle and Fat
§  Biotransformation (Liver)
–  Chemical transformation of the drug by enzymes
–  Enzymatic degredation by Cytochromes P450;
CYP3A4 and CYP2D6
§  Elimination (Kidney)
–  For a single dose, 4 half-lives are necessary before
a drug is 90% eliminated.
Typical BDZ for Dentistry
§ 
§ 
§ 
§ 
§ 
§ 
Triazolam (Halcion)
Diazepam (Valium)
Lorazepam (Ativan)
Alprazolam (Xanax)
Temazepam (Restoril)
Oxazepam (Oxpam)
§  Cardiovascular Effects
–  Minimal myocardial depression
–  High doses á HR â BP
§  Respiratory Effects
–  Minimal âRR â Volume as single agent
–  High doses â Hypoxic drive
Benzodiazapine Contraindications
§  Sleep Apnea
§  Paradoxical Reactions
14
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Is this a good choice?
§  Can your patient swallow pills?
–  Or do they need to be crushed/ground?
§  How is that airway?
–  Respect for sleep apnea!
Dose Selection
Effect on Body è
Optimizing Dose
Desired
Effect
Side
Effect
N2O Dose Selection
Amount of Drug è
N2O Ideal Sedation
N2O Over-Sedation
Symptoms
Signs
Symptoms
Signs
Relaxation
Decreased muscle tone
Laughing
Restlessness
Light-headedness
Transient increase in HR, BP
Dreaming
Sweating
Tingling of hands, feet, lips
Normal respiration
Tearing/crying
Tearing/lacrimation
Warmth
Periphreal vasodilation
Nausea
Vomiting
Dysphoria
Persistent increase in HR, BP, RR
Light “floating” to heavy “sinking”
feeling
Mild euphoria
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Nitrous Oxide % Dose Selection
§  20% is a good starting point
§  20-40% most patients enjoy distracting and
pleasant effects
§  >50% most patients experience side effects,
especially nausea/vomiting
§  70% may be required for some patients to feel
any effect, but this is rare
BDZ Dose Selection
–  Check for leaks!
BDZ Dose Considerations
§ 
§ 
§ 
§ 
§ 
§ 
Weight
Age
Systemic health
Concurrent medications
Chemical dependency
Anxiety level
Triazolam
Properties
Time (hours)
Onset of Action
0.5-1
Peak Serum Concentration
1-2
Duration of Action
~2
Elimination Half Life
1.5-5.5
Best for Appointments
<3
Available Oral Preparations
0.125 and 0.25 mg tablets
Dose Range
0.125-0.5 mg (0.004 mg/kg)
Diazepam (Valium)
Lorazepam (Ativan)
Properties
Time (hours)
Properties
Time (hours)
Onset of Action
0.5-1
Onset of Action
1-2
Peak Serum Concentration
0.5-2
Peak Serum Concentration
1-6
Duration of Action
2-4
Duration of Action
Up to 8
Elimination Half Life
20-80
Elimination Half Life
10-20
Best for Appointments
>2
Best for Appointments
>3
Available Oral Preparations
2, 5, and 10 mg tablets
Available Oral Preparations
0.5, 1, and 2 mg po and sl tablets
Dose Range
10-30 mg (0.065-0.3 mg/kg)
Dose Range
0.5-3 mg (0.02 mg/kg)
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Alprazolam (Xanax)
Temazepam (Restoril)
Properties
Time (hours)
Properties
Time (hours)
Onset of Action
1-1.5
Onset of Action
0.5-1
Peak Serum Concentration
1-2
Peak Serum Concentration
1.2-1.6
Duration of Action
4-6
Duration of Action
~4
Elimination Half Life
6-30
Elimination Half Life
3.5-18.4
Best for Appointments
>3
Best for Appointments
Data not available
Available Oral Preparations
0.25, 0.5, 1 and 2 mg tablets
Available Oral Preparations
15 and 30 mg capsules
Dose Range
0.25-0.5 mg
Dose Range
7.5-30 mg
Oxazepam (Oxpam)
Approximate Doses ASA I/II Patients
Properties
Time (hours)
Drug
Minimal
Moderate
Night Before
Onset of Action
~1
Triazolam (Halcion)
0.125-0.25 mg
0.375-0.50 mg
0.125-0.25 mg
Peak Serum Concentration
~2
Diazepam (Valium)
10-15 mg
20-30 mg
5-10 mg
Duration of Action
~3
2-3 mg
-
~8
Lorazepam
(Ativan)
0.5-1 mg
Elimination Half Life
Alprazolam (Xanax)
0.25 mg
0.5 mg
0.25 mg
Best for Appointments
Data not available
Available Oral Preparations
10, 15, and 30 mg capsules
Dose Range
10-30 mg
Temazepam (Restoril)
15 mg
20-30 mg
-
Oxazepam (Oxpam)
10-15 mg
15-30 mg
-
BDZ Dose Selection
BDZ Dose Selection
STEP 1: What is my sedation goal?
§  Weight
–  Minimal sedation
STEP 2: Begin with a weight-based dose
–  Use “ideal” not actual body weight
–  Must dose to lean body mass to avoid overdose
–  This is your starting point
STEP 3: Consider dose modifiers
–  Age/health status?
–  Liver enzymes?
–  Anxiety level?
–  Special reason to be cautious?
Ideal body weight (BMI):
http://www.halls.md/ideal-weight/body.htm
(Or estimate)
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BDZ Dose Selection
BDZ Dose Selection
Liver enzymes?
§  Enzyme induction? = need more drug
Anxiety level?
§  Mild anxiety?
–  Smoking/alcohol abuse
–  Daily benzodiazepines?
§  Enzyme inhibition? = need less drug
–  Stick to weight dose
§  Moderate anxiety?
–  Modest increase in dose
–  CYP3A4 inhibitors: erythromycin, clarithromycin,
azole antifungals, cimetidine, grapefruit juice
–  Age, poor systemic health
Example: Triazolam
Example: Triazolam
40 yo F 5’4” (64cm) 210 lbs (95kg)
Healthy, Non-drinker, Smokes ½ pack/day
Very anxious!
40 yo F 5’4” (64cm) 210 lbs (90kg)
Healthy, Non-drinker, Smokes ½ pack/day
Very anxious!
0.004 mg/kg x 90kg = 0.38 mg
Ideal body wt (based on BMI): 111-146 lbs
Pt is a heavy smoker and highly anxious, perhaps consider
an increase in dose for a minimal sedation effect?
For this example, assume 140 lbs; = 64 kg
Closest dose = 0.5 mg
Actual wt: 0.004 mg/kg x 90 kg = 0.38 mg
Ideal wt: 0.004 mg/kg x 64 kg = 0.25 mg
Closest dose? = 0.375 mg NOT 0.5 mg
Triazolam Dose for Minimal Sedation
Triazolam Dose for Minimal Sedation
I recommend 3 Triazolam dosing strategies:
Rationale for Triazolam dosing strategies:
0.125 mg
0.250 mg
0.375 mg
(0.5 mg)
Dose
Explanation
0.125 mg*
Usually poor effect for healthy patients with moderate anxiety; Use
for elderly, fragile (medically compromised), small patients based
on ideal body weight.
0.250 mg*
Likely good effect; base on ideal body weight. May be
unsatisfactory for highly anxious patients or those with enzyme
induction (current benzodiazepine, alcohol, or smoking)
0.375 mg**
May be minimal sedation when at previous appointment effect for
0.250 mg demonstrated to have limited or no effect.
(0.5 mg)
Most likely moderate sedation; avoid this dose.
*RCDSO recommended minimal sedation doses
**Possible moderate sedation – monitor effect closely to ensure minimal
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Continuum Depth of Sedation
§  It is not always possible to predict how a
patient will respond
§  Individuals administering sedation need to
be able to rescue patients who enter a state of
deeper sedation than intended
Examples of Minimal Sedation
§  40% N2O:O2
§  0.25 mg triazolam
§  0.125 mg triazolam + 30% N2O:O2 And….
patient answers you intelligibly when you ask a
question. You may have to gently touch them,
but they will respond rapidly and sensibly.
General Categories of Regulations
Objective 3
Establish policies and practices
in their office which comply with
RCDSO regulations.
§ 
§ 
§ 
§ 
§ 
§ 
Training and Education
Provider and Facility Permits
Facility Resources
Patient Evaluation
Documentation
Emergency Preparedness
Assumptions of Regulators
Sedation
Modality
Training & Education
Minimal
• 
•  N2O alone
•  1 drug
•  1 drug + N2O • 
Moderate
Multiple oral
medications
IV
Deep
• 
• 
Ketamine
Propofol
Monitoring
Basic
Increased
Advanced
Training
Basic
Increased
Advanced
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RCDSO Standards of Practice
Professional Responsibilities
RCDSO Standards of Practice
Professional Responsibilities
§  “Successful completion of a training program
designed to produce competency in the specific
modality of sedation utilized is mandatory.” (#1,
p.2)
§  “Training program must be obtained
from one or more of the following
sources” (i, p.6)
– Document your continuing education
– Include this course in your training
– Undergraduate or postgraduate program
– Continuing education courses
•  Teachers certified sedation/anesthesia
•  Permit candidates to utilize techniques**
RCDSO Standards of Practice
Professional Responsibilities
§  “Followed by a recorded assessment of
the competence of candidates.” (i, p.6)
•  Course where you have taken a test**
Provider & Facility
Permits
Do I need a provider permit for
minimal sedation with..
Do I need an office inspection for
minimal sedation with…
§  Oral benzodiazepines?
§  Oral benzodiazepines?
–  No.
§  Nitrous Oxide and Oxygen Sedation?
–  No.
–  No.
§  Nitrous Oxide and Oxygen Sedation?
–  No.
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RCDSO Guidelines
Section????
Facility Resources
§  “In order to avoid allegations of sexual
impropriety, additional appropriate
staff should be present in the treatment
room at all times whenever sedation is
used.” (#11 p.4)
– Alter cognition
– Dream-like state
– Sexual phenomena
RCDSO Standards of Practice
Additional Standards
RCDSO Standards of Practice
Sedation Equipment (p.9)
§  “1. Administration of Nitrous Oxide and
Oxygen”
§  Gas delivery system
§  “All automated monitors must receive
regular service and maintenance by
qualified personnel according to their
manufacturer’s specifications, or annually,
whichever is more frequent.”
§  “A written record of this annual
maintenance/servicing must be kept on
file for review by the RCDSO as required.”
– Scavenging
– Separate reserve “E” cylinder of oxygen
– Written record of annual maintenance/
servicing kept on file for review as required
Mandatory Equipment
Pulse Oximetry
§  Standard Emergency Medications +
§  The pulse oximeter is an essential monitor for
dentists who provide sedation
–  Reversal Agents (Flumazenil)
–  Ensure E-tank Oxygen (+Face Mask)
§  Blood Pressure Monitior
–  Manual stethescope and sphygomanometers of
appropriate sizes
§  Pulse Oximeter*
Introduced in the 1980’s
Noninvasive, inexpensive, simple monitor
of respiratory function
n  Detects hypoxemia
(↓oxygen in blood)
n 
n 
–  Audio alarm settings
*N/A nitrous alone, single oral agent alone
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How it works (3) – Physiology (A)
Physiology (B)
§  Hemoglobin is the active oxygen-carrying part of the
erythrocyte (red blood cell)
§  If all 4 Hb molecules bind with oxygen, there is
100% saturation
§  Pulse oximeters measure
arterial oxygen saturation,
(SaO2) which is the
affinity for oxygen binding
to hemoglobin and
physiologically related to
arterial oxygen tension
(PaO2) according to the
oxyhemoglobin (HbO2)
dissociation curve
Physiology (B)
Limitations (1)
§  If the oxygen unloads from
the Hb molecule to the
tissues and is not replaced,
the hemoglobin saturation
falls
§  Measures oxygen saturation, NOT content, therefore
cannot provide actual measure of tissue oxygenation
Limitations (2)
RCDSO Standards of Practice
§  Signal processing
§  “2. Oral Administration of a Single
Sedative Drug” Additional
Responsibilities (p. 8)
§  Ambient light
§  Low perfusion
§  Motion artifact
§  IV Substances
§  Dyshemoglobins
§  Intravenous dyes
§  Pigmentation
– Emergency Equipment
•  Full face masks of appropriate size and
connectors
•  Fumazenil
§  Skin
§  Nail polish
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14-11-24
Essential Emergency Drugs
N2O Reversal: 100% Oxygen
EASY!
DA Haas, Dent Clin N America, 2002
BDZ Reversal: Flumazenil (Anexate)
§  Antagonizes effect of benzodiazepines on
GABA receptor in the CNS
§  Contraindicated in patients given
benzodiazepine for control of epilepsy
§  0.1 mg/mL ONLY IV 0.1-0.2 mg increments
§  Onset 1-2 min, peak 6-10 min, duration 45
min (less than duration of benzodiazepine)
therefore caution to monitor and re-dose
§  Have the drug in your kit, call EMS, and let
the paramedics deliver it for you.
Patient Evaluation
RCDSO Guidelines
Professional Responsibilities
RCDSO Guidelines
Professional Reponsibilities
§  “Dentists must take into account the
maximum dose of local anaesthetic that
may be safely administered, especially
for children, the elderly and the
medically compromised.” (p.4)
§  “Whenever sedation is used, the
calculated maximum dose of local
anaesthesia may need to be further
adjusted to provide a greater margin of
safety” (p.4)
– Implies you calculate the maximum dosage
of LA for each patients
– Do you?!?!
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14-11-24
Calculating Max LA Dose
§  Patient-specific
§  Based on patient weight
§  # of cartridges simple way to keep track
3 Steps Max LA Dose
Step 1. How many milligrams of drug are in one cartridge?
–  Need to know
•  concentration of drug (%)
•  volume of cartridge you use (ml)
Step 2. What is the maximum dose for this patient?
–  Need to know
•  weight of patient (kg)
•  maximum recommended dosage of drug (mg/kg)
Step 3. How many cartridges can I give?
–  Max dose (mg)/Amount drug (mg) per cartridge = # cartridges
Step 1:
How many mg of LA in 1 Cartridge?
§  What percent concentration is your solution?
–  i.e. Lidocaine 2%
§  Percent solutions represent grams per 100 ml
–  i.e. 2% lidocaine = 20 mg/ml
§  1 North American cartridge = 1.8 ml
–  20 mg/ml x 1.8 ml = 36 mg of lidocaine
Step 2:
Maximum dose for your patient (mg)
Maximum Recommended Dose mg/kg (MAX)
Local
Anaesthetic
Adult
Articaine 4%
7 mg/kg (500 mg)
Lidocaine 2%
7 mg/kg (500 mg)
Mepivicaine 2%
(with
vasoconstrictor)
6.6 mg/kg (400 mg)
Mepivicaine 3%
(plain)
7 mg/kg (400 mg)
Prilocaine 4%
8 mg/kg (500 mg)
DA Haas, J Can Dent Assoc, Oct 2002
Step 2:
Maximum dose for your patient (mg)
Step 3:
Pt Wt MRD
Articaine
Adult 90 kg 7 mg/kg
§  Lidocaine 2%
Lidocaine
Adult 90 kg 7 mg/kg
Max Dose Pt
630 mg
500 mg
Maximum dose for your patient (cartridge)
–  500 mg is the MRD for a 90 kg patient
–  2% lidocaine has 36 mg in 1 cartridge
–  500/36 = 13
630 mg
500 mg
–  Maximum number of cartridges of 2%
lidocaine is 13.
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RCDSO Standards of Practice
Discharge
Fit for Discharge?
Alert
Oriented
Ambulatory
Recovering
Pain/Bleeding managed
Returned to the same condition as upon arrival
§  “All patients must be specifically assessed
for fitness for discharge” (iv, p.6)
§ 
§ 
§ 
§ 
§ 
§ 
RCDSO Standards of Practice
Additional Standards
RCDSO Standards of Practice
Additional Standards
§  “1. Administration of Nitrous Oxide and
Oxygen” Additional Standards (p.8)
§  “1. Administration of Nitrous Oxide and
Oxygen” Additional Standards (p.7)
§  “Recovery status post-operatively must
be specifically assessed and recorded by
the dentist, who must remain in the
facility until that patient is fit for
discharge.”
•  “Only fully recovered patients can be
considered for discharge unaccompanied.
•  If discharge occurs with any residual
symptoms, the patient must be
accompanied by a responsible adult.”
RCDSO Standards of Practice
RCDSO Standards of Practice
§  “2. Oral Administration of a Single
Sedative Drug” Additional
Responsibilities (p. 8)
§  “2. Oral Administration of a Single
Sedative Drug” Additional
Responsibilities (p. 8)
– Discharged when
•  Oriented (person, place, time)
•  Ambulatory
•  Vital signs stable (baseline)
•  Signs of increasing alertness
– Discharged to
•  The care of a responsible adult
– Discharged with
•  Postoperative W/V instructions
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Informed Consent
§  Separate written consent
§  Discussion about the medication and its
expected effects
Documentation
–  Relaxed, not asleep
–  Fuzzy memories (BDZ)
§  Written Pre-operative and Post-operative
instructions explained
RCDSO Standards of Practice
Additional Standards
RCDSO Standards of Practice
Additional Standards
§  “1. Administration of Nitrous Oxide and
Oxygen” (p.7) Can be administered by
§  “1. Administration of Nitrous Oxide and
Oxygen” (p.7)
– Trained dentist
– Trained registered nurse (RN, RPN)/
respiratory therapist (RT)
•  Dentist is present/immediately available
•  Patient received N2O sedation before
•  Dosage levels previously determined
and recorded by the dentist in pt chart
– Direct and continuous monitoring by DDS,
RN, or RT (Note: cannot be monitored by a
hygenist – DDS, RN or RT must always be
in the room)
– Never left unattended by DDS, RN or RT
RCDSO Standards of Practice
Additional Standards
§  “1. Administration of Nitrous Oxide and
Oxygen” Additional Standards (p.7)
– “….continuous clinical observation for level
of consciousness and assessment of vital
signs which may include heart rate, blood
pressure, and respiration preoperatively,
intraoperatively, and postoperatively, as
necessary”
RCDSO Standards of Practice
§  “2. Oral Administration of a Single
Sedative Drug” Additional
Responsibilities (p. 8)
–  Dose administered in-office
•  Except 1: facilitate sleep the night before
•  Except 2: sedation permits office arrival
–  Accompanied to* and from the office
–  Monitored by clinical observation of the
•  level of consciousness
•  assessment of vital signs (HR, BP, RR)
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RCDSO Standards of Practice
Written Record
§  “3. Oral Administration of a Single
Sedative Drug with Nitrous Oxide and
Oxygen Additional Responsibilities (p. 9)
§ 
§ 
§ 
§ 
§ 
§ 
§ 
§ 
–  Must be specifically trained, evaluated, and received
documentation of competency
–  Slow titration of nitrous oxide to avoid exceeding
minimal sedation
–  Continuous pulse oximeter monitoring
–  Audible audio output and alarms at all times
Updated MH
Pre-operative vital signs
Confirm NPO
Confirm Ride (if BDZ)
Drug, dose, duration of sedation
Post-operative vital signs
Discharge criteria met
Discharged to responsible adult (if BDZ)
Sample N2O Patient Record
Sample Oral Sedation Patient Record
§  Example: HH: See Sedation Consult form.
Reviewed health history with XX; no changes.
No solids since XX AM/PM, no liquids since
XX AM/PM. Pre-op BP XXX/XX, HR XX, RR XX.
Sedation start XX AM/PM. Nitrous oxide: X L
Nitrous at XX % for XX minutes, followed by
100% oxygen for 5 minutes. Patient conscious
and comfortable throughout. Sedation end XX
AM/PM. Post-op BP XXX/XX, HR XX, RR XX.
Post op instructions written and verbal given
to XX. Discharged at XX AM/PM: Vital signs
stable, awake, alert, ambulatory. !
§  Example: HH: See Sedation Consult form.
Reviewed health history with XX; no changes.
NPO since XX AM/PM, ride confirmed. Pre-op
BP XXX/XX, HR XX, RR XX. Sedation start XX
AM/PM. 0.25 mg triazolam po 45 min prior to
procedure with good effect for minimal
sedation (relaxed, comfortable). Pt immediately
responsive to verbal commands throughout.
Sedation end XX AM/PM. Post-op BP XXX/XX,
HR XX, RR XX. Post op instructions written
and verbal given to XX. Discharged at XX AM/
PM to father (George) taxi. VSS: awake, alert,
ambulatory. !
Sample Oral Sedation Patient Record
§  Example: HH: See Sedation Consult form.
Reviewed health history with XX; no changes.
NPO since XX AM/PM, ride confirmed. Pre-op
BP XXX/XX, HR XX, RR XX. Sedation start XX
AM/PM. 0.375 mg triazolam po 45 min prior to
procedure with adequate effect for minimal
sedation (anxiolyis, no hypnosis). Pt responded
normally with voice and light touch
throughout. Sedation end XX AM/PM. Post-op
BP XXX/XX, HR XX, RR XX. Post op
instructions written and verbal given to XX.
Discharge at XX AM/PM to adult (sister)
private car. VSS: awake, alert, ambulatory. !
Emergency
Preparedness
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RCDSO Standards of Practice
Professional Responsibilities
§  “All dentists and office staff must be
prepared to recognize and treat adverse
responses using appropriate emergency
equipment and appropriate and current
drugs when necessary.” (p.3)
Sedation Emergency
§  “Should the administration of any drug produce
depression beyond that of conscious sedation,
the dental procedure should be halted.
Appropriate support procedures must be
administered until the level of depression is no
longer beyond that of conscious sedation, or
until additional emergency assistance is
effected.” (iii, p.6)
RCDSO Standards of Practice
Professional Responsibilities
§  (p.3) Written protocols for emergency
procedures
–  Review with staff regularly
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RCDSO Standards of Practice
Professional Responsibilities
§  (p.3) BLS (CPR Level HCP)
–  Current certification strongly recommended
Why Recertify?
Why Recertify?
§  Evidence suggests the retention of BLS
and ACLS knowledge and skills is poor
§  Dental students trained in CPR not capable of
managing a cardiac arrest 3 months later Laurent
–  After a 1 day course, 1 year later MDs and
RNs show significant deterioration, with
performance returning to pre-training levels
Gass & Curry Can Med Assoc J 1983
–  After BLS course, 6 months later no MD or RN
performed all management steps correctly
Kay & Mancini Crit Care Med 1986
et al J Dent Educ 2009
–  >50% judge themselves competent in CPR
–  50% failure to check for circulation
–  50% failure to deliver adequate compressions
§  Dentists trained in CPR lack knowledge and
confidence Gonzaga et al Brazil Dent J 2003
–  59% judge themselves competent; but only 46% can
correctly identify BLS concepts
BLS: Circulation-Breathing-Airway
What matters is rescue
§  C: Circulation
§  “It is reasonable for healthcare
providers to tailor the sequence of
rescue actions to the most likely
cause”
– Heart sends oxygen to brain
§  B: Breathing
– Lungs send oxygen to blood for heart
§ A : Airway
–  AHA Guidelines 2010
– Patent airway provides oxygen to lungs
Sedation can compromise all of these systems.
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Signs of Airway Obstruction
Head-Tilt Chin-Lift
§  Snoring
§  Exaggerated Respiratory Effort
–  Use of accessory muscles
§  (Wheezing)
§  (Stridor)
§  Absence of breath sounds
UPPER AIRWAY ANATOMY
Head-Tilt Chin-Lift
§  Upper airway obstructed §  Head-tilt chin lift opens
by tongue in oropharynx
upper airway
Head tilt–chin lift.
Jaw thrust without head tilt.
. Circulation 2000;102:I-22-I-59
. Circulation 2000;102:I-22-I-59
Copyright © American Heart Association, Inc. All rights reserved.
Copyright © American Heart Association, Inc. All rights reserved.
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UPPER AIRWAY
Oral Airway Insertion
§  Oropharyngeal airway
may help to maintain
patency
Face shield.
Mouth-to-mask, cephalic technique.
. Circulation 2000;102:I-22-I-59
. Circulation 2000;102:I-22-I-59
Copyright © American Heart Association, Inc. All rights reserved.
One-rescuer use of the bag mask.
. Circulation 2000;102:I-22-I-59
Copyright © American Heart Association, Inc. All rights reserved.
Two-rescuer use of the bag mask.
. Circulation 2000;102:I-22-I-59
Copyright © American Heart Association, Inc. All rights reserved.
Copyright © American Heart Association, Inc. All rights reserved.
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Sedation Ready
§  “What’s my action list to be able to do
minimal sedation in my office tomorrow?”
Putting it all together
Patient Evaluation
Patient Preparation
q  Current, updated medical history
q  Indication for sedation
q  Core Physical Exam (Vital Signs)
q  Core Medical History
q  NPO (2 hrs nitrous, 4 hrs BDZ)
q  Ride (BDZ)
q  Written Post-operative instructions
q  Functional Inquiry (RESP, CVS)
q  Airway assessment
q  Assign ASA Status
q  Max LA Dose Calculation
Provider Preparation
Facility Preparation
q  Appropriate Training
q  Current BLS (Healthcare provider)
q  Sedation Assistant
q  Functioning equipment, maintained
–  Patient cannot be left unattended
–  You cannot be alone with the patient!
q  Emergency Protocols
q  Basic Medical Emergency Drugs
q  E-tank Oxygen (separate supply)
q  Ambubag (full face mask, with connectors)
q  Manual stethescope and sphygomanometers
q  Flumazenil (if using benzodiazepines)
My additional Recommendations:
q  Pulse oximeter
q  Selection of oral airways
32
PATIENT INSTRUCTIONS Nitrous Oxide and Oxygen Conscious (Minimal) Sedation
Nitrous Oxide and Oxygen Sedation is a safe and effective method to limit anxiety and create relaxation. Follow these instructions carefully. They are for your safety. BEFORE THE APPOINTMENT 1. DO NOT EAT OR DRINK: NO FOOD OR DRINK within 2 hours of your dental appointment. The last meal before your appointment should be a light, low-­‐fat meal (avoid dairy, no fried fatty food). The last drink before your appointment should be water, clear juice (apple juice), or black coffee (avoid dairy or dairy substitutes) as these are easy to digest. Last Meal -­‐ Light, Low-­‐Fat LAST SOLID FOOD LAST DAIRY DRINK 2 HRs 1 NO FOOD NO DRINK Appointment 3. MEDICATIONS: Take all regular medications at their usual time, with sips of water only. In rare instances, you may be asked not to take a certain medication. If you are not sure, check with your student. 4. WHAT TO WEAR: Loose, comfortable clothing is best. Do not wear nail polish. 5. ILLNESS: If you become sick or ill at anytime leading up to your appointment, call your student. Report any health changes such as new medical diagnosis, new illness, cough/fever, cold or flu. Bring an updated medication list to your appointment and be prepared to answer questions about your health. AFTER THE APPOINTMENT 1. ACTIVITIES: Following the administration of 100% Oxygen for five minutes, you should be fully recovered from the sedation and can resume your normal activities. 2. FOOD AND DRINK: Depending on your dental treatment, you may need to modify your diet. It is important to resume fluid intake after your appointment to prevent dehydration. Make sure you resume drinking following your sedation. Start with small sips of water and drink more as able. Student Name: ______________________________________________________________ Daytime Phone: 416-­‐979-­‐4900 Ext. ___________ OR ________________________________ After hours or in an emergency, contact your nearest hospital emergency department. 101 Elm Street Toronto ON M5G 1G6
PATIENT INSTRUCTIONS Oral Conscious (Minimal) Sedation Oral Conscious Sedation is a safe and effective method to limit anxiety and create relaxation. Follow these instructions carefully. They are for your safety. BEFORE THE APPOINTMENT 1. MAKE PLANS FOR GETTING HOME: You will not be able to drive after your appointment. Under no circumstances may you use public transportation. You may only go home in 1) a private vehicle or 2) a taxi. You must have a responsible adult to escort you home. You must go directly to a place where you can rest. You escort should arrive to _____________________________________ at _______________ to pick you up. 2. DO NOT EAT OR DRINK: For best absorption of the sedative medication. do not eat within 4 hours of your dental appointment. The last meal before your appointment should be a light, low-­‐fat meal (avoid dairy, no fried fatty food). WATER, CLEAR JUICE, and BLACK COFFEE (NO DAIRY or dairy substitutes) are easy to digest and allowed up to 2 hours before your appointment. NO FOOD OR DRINK within 2 hours of your appointment. Last Meal – Light, Low-­‐Fat LAST SOLID FOOD LAST DAIRY DRINK 4 HRs 3 2 HRs 1 NO FOOD NO FOOD Water, clear juice, black coffee ONLY NO DRINK Appointment 3. MEDICATIONS: Take all regular medications at their usual time, with sips of water only. In rare instances, you may be asked not to take a certain medication. If you are not sure, check with your student. 4. WHAT TO WEAR: Loose, comfortable clothing is best. Do not wear nail polish. 5. ILLNESS: If you become sick or ill at anytime leading up to your appointment, call your student. Report any health changes such as new medical diagnosis, new illness, cough/fever, cold or flu. Bring an updated medication list to your appointment and be prepared to answer questions about your health. AFTER THE APPOINTMENT 1. ACTIVITIES: After your appointment, your motor coordination and cognitive function will be impaired. You may not operate a motor vehicle or machinery, consume alcohol, engage in decision-­‐making, business transactions, or online social media for 18 hours, or longer if dizziness/drowsiness persists. Rest is best. 2. FOOD AND DRINK: Depending on your dental treatment, you may need to modify your diet. It is important to resume fluid intake after your appointment to prevent dehydration. Make sure you resume drinking following your sedation. Start with small sips of water and drink more as able. 3. SEEK ADVICE: If you have difficulty breathing, nausea or vomiting that persists beyond 2 hours, a sensation of dizziness or drowsiness 6-­‐8 hours after your appointment, or any other matter that causes you concern. Student Name: ____________________________________________________________________________ Daytime Phone: 416-­‐979-­‐4900 Ext. ___________ OR ______________________________________________ After hours or in an emergency, please contact your nearest hospital emergency department. 101 Elm Street Toronto ON M5G 1G6
1-2
1 - 1.5
0.5 - 1
Lorazepam
Ativan™
Alprazolam
Xanax™
Temazepam**
Restoril™
~2
1.2 -1.6
1 -2
1-6
0.5 - 2
1-2
Peak
Serum
Concentration
~3
~4
4-6
Up to 8
2-4
~2
Duration
of Action
~8
3.5 - 18.4
6 - 30
10 - 20
20 - 80ǂ
1.5 - 5.5
Elimination
Half-Life
10, 15 and 30 mg
tablets
15 and 30 mg
capsules
10 - 30mg
7.5 - 30 mg
0.25 - 0.5 mg
0.5 - 3 mg
(0.02 mg/kg)
0.5, 1 and 2 mg
oral and SL
tablets
0.25, 0.5, 1, and
2 mg tablets
10 - 30 mg
(0.065 - 0.3 mg/kg)
0.125 - 0.5 mg
(0.004 mg/kg)
Oral (PO) Dose
Range
For Adult Patients
2, 5, and 10 mg
tablets
0.125 and 0.25
mg tablets
Available Oral
(PO)
Preparations
10 - 15 mg
15 mg
0.25 mg
0.5 - 1 mg
10 - 15 mg
0.125 –
0.25 mg
Minimal
Sedation
15 - 30 mg
20 - 30 mg
0.5 mg
2 - 3 mg
20 - 30 mg
0.375 0.50 mg
Moderate
Sedation
-
-
0.25 mg
-
5-10 mg
0.125 0.25 mg
Night
before
Approximate Doses for Adult
Patients, ASA I or II*
Data not
available
Data not
available
> 3 hrs
> 3 hrs
> 2hrs
< 3 hrs
Best for
dental
appointment
durations
C Yarascavitch, D Munyal, D Haas. Discipline of Dental Anaesthesia, Faculty of Dentistry, University of Toronto ©2014. Contact authors for distribution other than personal use.
ǂ Correlates roughly with patient age.
** Temazepam and Oxazepam have been poorly studied in the dental model. Doses are approximations based on their use in alternate clinical
contexts.
* For patients who are ASA III or elderly, doses should be reduced. Concurrent use of inhalational agents such as nitrous oxide should be titrated
carefully to avoid oversedation. Increased duration of action in these patients may require an increased duration of monitoring.
~1
0.5 - 1
Diazepam
Valium™
Oxazepam**
Oxpam™
0.5 - 1
Onset
of
Action
Triazolam
(Formerly
Halcion™)
Drug
Time (hours)
Oral Conscious Sedation Agents: Pharmacology & Suggested Regimens