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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 1 14-11-24 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 ðModerate ðDeep ðGA Sedation Anxiolysis Amnesia Hypnosis 2 14-11-24 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 3 14-11-24 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 ! 4 14-11-24 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 5 14-11-24 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 6 14-11-24 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 7 14-11-24 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 8 14-11-24 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 9 14-11-24 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 14-11-24 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 11 14-11-24 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 12 14-11-24 N2O Pharmacodynamics N2O Contraindications § Respiratory Effects § § § § § § – Weak respiratory depressant (êvolume) – Mild sympathomimetc (érate) • 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? 13 14-11-24 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 âRR â Volume as single agent – High doses â Hypoxic drive Benzodiazapine Contraindications § Sleep Apnea § Paradoxical Reactions 14 14-11-24 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 15 14-11-24 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) 16 14-11-24 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) 17 14-11-24 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 18 14-11-24 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 19 14-11-24 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. 20 14-11-24 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 21 14-11-24 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 22 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?!?! 23 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. 24 14-11-24 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 25 14-11-24 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) 26 14-11-24 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 27 14-11-24 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 28 14-11-24 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. 29 14-11-24 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. 30 14-11-24 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. 31 14-11-24 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
