Post on 03-Jun-2018
8/12/2019 Dental Hygienists - Sedation Overview
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Oral Sedation - A
Review
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Review Description• Over view of legal environment
‣ Review ASA Health Classification
‣Individual Drugs
‣ Overview Oral Sedation Regimens
‣ Recovery
‣Appointment Framework
‣ Review NPO Guidelines
‣ Urgencies
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Course Objectives‣ know the newest NPO guidelines
‣ understand the pharmacology of the more frequently
used medications used in oral sedation
‣ be able to choose an oral sedation regimen appropriateto the treatment needs of the patient and understand
the limitations of that choice
‣ be aware of the most common urgencies
‣ understand appropriate treatment plans used during
the more frequent sedation urgencies
‣ be able to arrange a safe oral sedation appointment in
their daily practice
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Conflicts of InterestCommercial Support
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Multiple Guidelines
• Hospital Guidelines
• College of Dentistry Guidelines
• ASA Guidelines for Sedation by theNon-Anesthesiologist
• ADA Guidelines for the Use of
Conscious Sedation, Deep Sedationand General Anesthesia by Dentists
• AAOMS & AAPD Guidelines
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ADA Guidelines
www.ada.org/sections/about/pdfs/anesthesia_ guidelines.pdf
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Ohio Regulations
New York Regulations
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NY Regulations
Oral Sedation Dentistry RegulationsNew York State
Board for Dentistry Rule §61.10 (c)(iii)(a)(2)(ii)
requires a dentist to complete at least 18 hours ofuniversity-based didactic training with 20 clinical
patient experiences, and obtain a permit before
administering Oral Conscious Sedation to their
adult patients.** When the intent is Anxiolysis only, a permit is not
required.
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Dental Enteral Conscious Sedation certificate authorizes a licensed dentist to
employ conscious sedation (enteral route only with or without inhalation
agents).You must present evidence of completion of either:pre-doctoral or
post-doctoral education consisting of a specialty program or residency
accredited by an acceptable accrediting body which includes coursework inBasic Life Support and additional coursework consisting of at least 18 clock
hours, including but not limited to, instruction in nitrous oxide use and
emergency management. In addition to the coursework, you must complete
20 clinically-oriented experiences in the use of enteral conscious sedation
techniques. These clinically-oriented experiences may include groupobservations of patients undergoing enteral conscious sedation techniques;
orpost-doctoral coursework approved by the Department which has
equivalent rigor as coursework approved by an acceptable accrediting body
and which includes coursework in Basic Life Support and additional
coursework consisting of at least 18 clock hours, including but not limited to,instruction in nitrous oxide use and emergency management. In addition to
the coursework, the program must require 20 clinically-oriented experiences
in the use of enteral conscious sedation techniques. These clinically-oriented
experiences may include group observations of patients undergoing enteral
conscious sedation techniques.permit.
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NY Regulations
• NYU's 22-hour Enteral Sedation at NYU
course is approved by the New YorkState Board for Dentistry as meeting
the 18-hour university-based didactic
training requirement for the NY enteralsedation permit.
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NY Regulations
Conscious sedation means a minimallydepressed level of consciousness thatretains the patient's ability toindependently and continuously
maintain an airway and respondappropriately to physical stimulationand verbal command and that isproduced by a pharmacologic or non-pharmacologic method or a combinationthereof. Patients whose only response isreflex withdrawal from repeated painful
stimuli shall not be considered to be ina state of conscious sedation.
http://www.op.nysed.gov/prof/dent/dentanesthes.htm
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ASA
•ASA PS 1 A normal healthy patient
•ASA PS 2 A patient with mild systemic disease
•ASA PS 3 A patient with severe systemic disease
•ASA PS 4 A patient with severe systemic disease that is a constant
threat to life
•ASA PS 5 Moribund, not expected to live 24 hours without the
operation
•ASA PS 6 A declared brain-dead patient who organs are being
removed for donor purposes
-An E is added to the status number to designate an emergency
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The value of ASA classification, perioperative risk, (especially
postoperative morbidity), analyzed using data of 2937 patients. Account for validity, reliability, and sensitivity.
Differences between the ASA classes were confirmed (p-value < 0.05)
considering separate kinds of complications and different periods.
Furthermore, ASA classification was a valuable reference to length of
stay and severity of necessary therapy at the ICU.
Implications?
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Goals of Sedation• Provide age-appropriate care to all patients by ensuring that
the clinical providers have the appropriate clinical
competencies.
• Achieve adequate sedation with minimal risk. Minimizediscomfort and pain.
• Minimize negative psychological responses by providing
adequate sedation, analgesia and amnesia.
• Decrease agitation and improve cooperation during aprocedure.
• Provide for rapid recovery and safe discharge.
• Facilitate Improved technical performance of the procedure.
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Medications
Over View
• Traditional agents - see Malamed
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Half-Life ?
A) t1/2 alpha - or the distribution half life
B) t1/2 beta - or the elimination half life
C) context-sensitive half-life - is defined as the
time taken for blood plasma concentration of a
drug to decline by one half after an infusiondesigned to maintain a steady state (i.e. a
constant plasma concentration) has been
stopped. The "context" is the duration of infusion.
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Half-Life ?
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Half-Life ?
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Half-Life ?
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Half-Life ?
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Half-Life ?
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Half-Life ?
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Medications Specific
• Versed
• Demerol
• Phenergan
• Hydroxyzine
• Chloral Hydrate
• Halcion
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Versed
• Depresses all levels of CNS
• T max is 0.17 to 2.65 h
• Approximately 97% is protein bound (mainly to albumin)
• Midazolam is subject to substantial intestinal and hepatic first-pass metabolism by CYP-450 3A4. Active metabolite is
alpha-hydroxymidazolam
• Onset is 10 to 20 min
• Hepatic Function Impairment: Following oral administration (15 mg),
C max and bioavailability were 43% and 100% higher, respectively.
Cl was reduced 40% and t ½ increased 90%. Doses should be titrated.
• CHF: Following oral administration (7.5 mg), t ½ increased 43%
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Demerol (Meperidine)•Meperidine protein binding is high
•Opioid Analgesic
•t ½ is 3 to 4 h
•10 to 45 min
•The times to peak effect are 3 to 50 min
•Children (IM/Subcutaneous), 60 to 90 min (oral), and 5 to
7 min (IV)
•ChildrenIM/Subcutaneous/PO 1 to 1.8 mg/kg
•Potentially fatal reactions can occur if meperidine is used in
patients within 14 days of receiving MAOI
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Hydroxyzine
• Atarax is not a cortical depressant, ?subcortical area.
• Primary skeletal muscle relaxation has been demonstrated.
• Bronchodilator, anti- histaminic and analgesic activity have
been demonstrated.
• Antiemetic effect.
•Does not increase gastric secretion or acidity.
• Rapidly absorbed from the gastrointestinal tract effects in 15
to 30 minutes after oral administration
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Chloral Hydrate
• Exact mechanism is unknown; can produce mild CNS
depression.
• 35% to 41% protein bound (trichloroethanol). Excreted in
breast milk
• Metabolized to trichloroethanol (active), which is then
converted in liver and kidney to trichloroacetic acid
(inactive)
• EliminationThe half-life is 7 to 10 h
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Halcion(triazolam)• Triazolam is a hypnotic with a short mean plasma half-life reported to
be in the range of 1.5 to 5.5 hours. In normal subjects treated for 7
days with four times the recommended dosage, there was no
evidence of altered systemic bioavailability, rate of elimination, or
accumulation. Peak plasma levels are reached within 2 hours
following oral administration
• CYP 3A - metabolism
• Coadministration of erythromycin increased the maximum plasma
concentration of triazolam by 46%, decreased clearance by 53%, and
increased half-life by 35%
• Coadministration of cimetidine increased the maximum plasma
concentration of triazolam by 51%, decreased clearance by 55%, and
increased half-life by 68%
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Regimens
• Short
• Quadrant Dentistry
• Older Children / Quadrant Dentistry
• Older Children
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Regimens• Short (e.g. ext single tooth)
‣ Versed (oral) 0.5-1mg/kg to max
20mg
‣ Versed (nasal) 0.5mg/kg to max
15mg - uncoop, young children
✦We also have used the Nasal onour autistic patients with good
success
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Regimens
•Quadrant Dentistry
‣ Versed 0.5-1mg/kg to max 20mg‣Demerol 0.5-2mg/kg to max 50mg
•sometimes might add Phenergan
1-2mg/kg
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Regimens
• Older Children / Quadrant Dentistry
‣Chloral Hydrate 35-50mg/kg to max1000mg
✦+ Demerol 0.5-2mg/kg to max
50mg✦+ Atarax 0.5-1mg/kg
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Regimens
• Older Children
‣Halcion 0.25mg tablets x 2
‣Demerol 5-15mg tablets
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Appointment
• Preop-assessment
Instructions
• Intraop
•Postop-assessment
Instructions
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Informed Consent• There are 4 components of informed consent:
• You must have the capacity (or ability) to make the decision.
• The medical provider must disclose information on the
treatment, test, or procedure in question, including the
expected benefits and risks, and the likelihood (or probability)
that the benefits and risks will occur.
• You must comprehend the relevant information.
• You must voluntarily grant consent, without coercion or
duress.
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NPO
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NPODelayed Gastric Emptying Disorders of gastric motility, pyloric obstruction,
gastroesophageal reflux and diabetic gastroparesis delay gastric
emptying. Indigestible solids are the first to be affected,
followed by digestible solids and finally liquids. Because the
rate of gastric emptying of clear fluids is not affected until these
conditions are far advanced, most patients may still be allowed
to drink on the morning of surgery. Different investigators have
found obese patients to have either a larger [16] or smaller [17]
residual fasting gastric fluid volume than non-obese patients.These comments only apply to patients scheduled for elective
surgery. All emergency cases, especially those involving trauma
and women in labour, should always be assumed to have
delayed gastric emptying.
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NPO
Gastric emptying is normal in all three trimesters of
pregnancy and beyond 18 hours post-partum, but is
delayed in the first 2 hours post-partum.[18] Labour
causes an unpredictable delay in gastric emptying that
is markedly potentiated by opioids.[19] Nevertheless,
there is a move towards less rigid fasting guidelines
during labour, especially in women who are notexpected to require operative intervention.
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NPOConclusion
The order 'nothing by mouth after midnight' should apply only to
solids for patients scheduled for surgery in the morning. An early
light breakfast of easily digested toast or similar food with clearliquid is permissible for afternoon cases. Clear liquids should be
allowed until 3 hours before the scheduled time of surgery so that a
change in the surgical schedule can be made and still allows 2
hours before the actual time of surgery. For patients with true
gastroesophageal reflux, whether or not they drink, an H2-receptor blocker (ranitidine) or proton pump inhibitor (omeprazole) may be
advisable to minimize gastric acid secretion.
NPO
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NPO
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Summary
Fasting times apply to all ages
Clear = water, fruit juice without pulp, black coffee
Light Meal = dry toast, clear liquid. Fatty foods may prolong gastric emptying
No routine use of GI stimulants, acid secretion blockers or oral antacids
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Monitoring
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Monitoring
• To observe and evaluate a function of
the body closely and constantly
• Permits early detection of adverseevents
• Risk Management Committee
• By 2000: 50 States regulated GA, CS
and 3 oral sedation
Is it necessary?
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Is it necessary? (percentage not
monitored)• 43 Cases
• HR - 68
• RR - 77
• BP - 77
• Oxygenation - 92
• H Rhythm - 96
Can’t detect moderate changes
Result - too little, too late
M it i /D t
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Monitoring/Documenta
tion Enteral/Enteral-Inhalation
• Patient Evaluation
• Pre-Operative Preparation
• Personnel
• Equipment
R ti P O
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Routine PreOp
Monitoring• BP
• HR
• Hrhythm
• RR
• Temp
• Height
• Weight
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Monitoring
• Direct Clinical Observation of the
Patient must occur• Oxygenation
• Ventilation
• Circulation
O ti
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Oxygenation
• Color of Mucosa, Skin, Blood• Pulse Oximetry
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Pulse Oximetry
• 70% of episodes SpO2 <81 not
detected visually by anesthesiologist
• SpO2 varies with age, pulmonary-
cardiovascular health, ambient oxygen
concentration, altitude
• SpO2 = HbO2 / HbO2+Hb
Time Lag
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Pulse Oximeter
• Distinguishes Between Oxygenated
Hemoglobin and Deoxygenated
Hemoglobin
• Deoxyhemoglobin - 600-750nm
• Oxyhemoglobin - 850-1000nm
• Two LEDs at 660nm & 940nm
• Indirect Measure of PaO2
O h l bi
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Oxyhemoglobin
Dissociation Curve• Relates SpO2 to PaO2
• Normal PaO2 Healthy Child
• 90 - 100 mmHg O2
• Equals SpO2 > 98%
• Based on Room Air O2= 21% FiO2
• Supplemental O2 Higher PaO2
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99
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95
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90
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Pulse Oximeter
• 5% Error in range of 70% - 100%
• Data averaged over 5 - 8 Seconds
• Desaturation Response Time:
• Ear - 7 - 20 Seconds
• Finger 20 - 35 Seconds
• Toe 41-73 Seconds
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Pulse Oximeter -
Errors• Low Pulse Amplitude
• Movement
• Anemia less than 10%
• Dyshemoglobins
• Carboxyhemoglobin
• Methemoglobin
• Sickle Cell Anemia
• Dyes, Electrocautery, Fingernail Polish, Skin
Pigment
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Ventilation• Chest Excursions• Difficult with Draped Patient
• Pre-Tracheal/Cordial Stethoscope
• Continuous, Immediate Evaluation of
Ventilation
• Heart Sounds Can Be Monitored As
Well
• Capnography
• Evaluates Expired CO2
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Capnography• Measures Concentration of Expired CO2
• Value Accurate for Intubated Patient
• Approximation of PaCO2 (Lower by ~ 7mmHg)
• Waveform Several Seconds Delayed
• Waveform Indirect Eval. of Respiration Quality
• Trend Value for Non-Intubated Patient
• Waveform Indicates Respiration Only
• Relatively Expensive
• Inspired Gases Can Also Be Measured
Carbon Dioxide
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Carbon Dioxide
Monitoring
• Infrared
• Endtidal Levels
• Wave Form
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Respiratory Rate
Neonate 40
1yr 25
5yr 20
12yr 16
21yr 12
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Circulation
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Circulation• Blood Pressure
• Width of Cuff 20% Greater Than Arm Diameter
• Cuff Too Narrow or Too Loose Elevated BP
• Less Error Too Wide Than Too Narrow
• Pulse Rate
• Brachial or Radial
• Rate, Rhythm, Regularity & Quality
• Electrocardiogram
• Dysrythmia Recognition
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Electrocardiography
• HR & Rhythm
• 12 / 5 / 3 lead
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Pulse
• Regular Intervals (q15’, q5’)
•With Deep Sedation / GA continuousmonitoring required
Terms
• continual - repeated regularly and frequently ina steady succession
• continuous - prolonged without any interruption
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Pulse
• Newborn 120
•1yr 120
• 5yr 100
• 10yr 90
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Blood Pressure
• 200/115 = ASA IV
• After administration of drug or changein rate of administration
• Automatic / Manual BP - w/wo
stethascope
• ! IV / SpO2
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Common BP
• Newborn 80/45
•Infant 100/60
• Child 110/60
• Teenager 120/60
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Temperature
• Not usually Critical
• Important to determine ± fever
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CNS
• BIS - monitor
100 - wide awake
85-90 - eye opening 80 - amnesia
60 - likely to be unconscious, positive
amnesia
• 60 second lag
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Monitoring Summary
• Oxygenation
• Color
• Mucosa, Skin, Blood
• Pulse Oximetry
• Ventilation
• Chest Excursions
• Auscultate Breath Sounds
• Capnography
• Circulation
• Blood Pressure
• Heart Rate
• Electrocardiography
• Temperature
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Recovery & Discharge
•Oxygen and suction equipment must beimmediately available in the recovery areaand/or operatory.
•Continual monitoring of oxygenation, ventilationand circulation when the anesthetic is no longerbeing administered; patient must have
continuous supervision until oxygenation,ventilation and circulation are stable and thepatient is appropriately responsive for dischargefrom the facility.
Recovery/Discharge
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Recovery/Discharge
contd.•Must determine and document that oxygenation,ventilation and circulation are stable prior todischarge.
•Must provide explanation and documentation ofpostoperative instructions to the patient and/or aresponsible adult at the time of discharge.
•The dentist must determine that the patient hasmet discharge criteria prior to leaving the office.
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Temperature
• Required When Triggering Agents for
Malignant Hyperthermia Planned
• Slightly Elevated Temperature Not
Uncommon Prior to Procedure Or May
Signal Impending Illness
• Elevated Temperature IncreasesCardiac and Respiratory Workload
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Personnel
• Conscious Sedation
• Operator + Surgical
Assistant/Monitor
• Deep Sedation/General Anesthesia• Operator, Surgical Assistant,
Dedicated Patient Monitor
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Documentation• Documentation in the medical record
• Consent (obtain if possible)
• Indications and any contraindications for theprocedure;
• ASA physical classification
• Medications used, and dosages
• Any complications and who was notified of
any complications (family, attending MD)
Sedation Record
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Sedation Record
• Time Oriented Record• Preferably Contains All Information Relative toSedation
• Pertinent Medical History Findings
• NPO Status
• IV Site
• Time/Doses of Sedative
• Vital Signs Every 10 Min
• BP, HR, SpO2
• Amount of Local Anesthetic Administered
• Nitrous Oxide/Supplemental Oxygen
OSDB Rules Enteral Oral
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OSDB Rules – Enteral Oral
Conscious Sedation
• The Use Of A Single Drug Administered Orally
Or Sublingually At One Time On A Given
Treatment Day
• Or Combination Of Drugs Administered
Concomitantly At One Time On A Given
Treatment Day.
• Not For IV Sedation/GA Providers
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Recovery
Aldrete Scoring
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Activity Respiration Circulation Consciousness Colour
2Moves all
extremities
voluntarily/ on
command
Breaths deeply
and coughs
freely.
BP + 20 mm of
preanesthetic
level
Fully awake Pink
1Moves 2
extremities
Dyspneic,
shallow or
limited breathing
BP + 20-50 mm
of preanesthetic
level
Arousable on
callingPale & Dusky
0Unable to move
extremities Apneic
BP + 50 mm of
preanestheic
level
Not responding Cyanotic
Aldrete Scoring
Modified Aldrete Scoring
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Vital Signs
(BP and
Pulse)
ActivityNausea and
Vomiting
PainSurgical
Bleeding
2Within 20% of
preoperative
baseline
Steady gait, no
dizziness
Minimal: treat
with PO meds
Acceptable
control per the
patient;
controlled with
PO meds
Minimal: no
dressing
changes
required
120-40% of
preoperative
baseline
Requires
assistance
Moderate: treat
with IM
medications
Not acceptable
to the patient;
not controlled
with PO
medications
Moderate: up to
2 dressing
changes
0>40% of
preoperative
baseline
Unable to
ambulateContinues: repeated treatment
Severe: more
than 3 dressing
changes
Modified Aldrete Scoring
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Escort/Discharge
• Stable Vital Signs/Awake/Ambulatory
• Escort Must Be Present On Discharge
•Escort Must Be Responsible Adult
• Post-Op Instructions To Escort & PreferablyWritten
• Must Have Escort During Early Recovery
Period At Home• Patient Cautioned Regarding Making Important
Decisions Later In Day
(When is a patient safe for discharge)
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Top 7 Emergencies
• syncope
• mild allergic reactions
• angina pectoris
• postural hypotension
• seizures
• bronchospasm
• hyperventilation
Critical Noninjectable
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Critical Noninjectable
Drugs• Oxygen
• Vasodilator• Bronchodilator
• Antihypoglycemic
• Aspirin