Conscious Sedation

Dr. Rahaf Al-Habbab BDS. MsD. DABOMSDiplomat of the American Boards of Oral and Maxillofacial

Surgery

Why Do Most People Avoid Going To The Dentist?

FEAR

Office Anesthesia

• To facilitate surgery and patient comfort• Amnesia• Analgesia• Conscious Sedation• Ambulatory General Anesthesia (No Intubation)• Hypnosis• Immobilization

Ambulatory General Anesthesia

Selective use of sedative and anesthetic agents designed to produce a brief period of anesthesia and to facilitate a rapid

recovery period after the termination of the procedure

• Patient has a brief post-operative recovery period

• Patient can ambulate after the termination of anesthesia

IV Sedation

A 30 year-old male patient, comes to your office for consultation for extraction of hi maxillary and mandibular

third molars, He asked to be sedated.

How will you assess this patient?

Pre-Operative Evaluation

• PMH• Medication, Allergies• ASA Classification• Vital Signs: BP, Pulse, RR, Oxygen Saturation, Height, Weight• Physical Exam• Airway Exam

Pre-Operative Evaluation

• PMH• Medication, Allergies• ASA Classification• Vital Signs: BP, Pulse, RR, Oxygen Saturation, Height, Weight• Physical Exam• Airway Exam

ASA Classification

General Pre-Anesthetic Evaluation American Society ofAnesthesiologists (ASA) Physical Status Classes

ASA I A normal healthy patientASA II A patient with mild systemic disease or significant health risk factorASA III A patient with severe systemic disease that is not incapacitatingASA IV A patient with sever systemic disease that is a constant threat to life ASA V A patient who is not expected to survive without the operationASA VI A declared brain dead patient whose organs are being Removed for donor purposes

Pre-Operative Evaluation

• PMH• Medication, Allergies• ASA Classification• Vital Signs: BP, Pulse, RR, Oxygen Saturation, Height, Weight• Physical Exam• Airway Exam

Pre-Operative Evaluation

• PMH• Medication, Allergies• ASA Classification• Vital Signs: BP, Pulse, RR, Oxygen Saturation, Height, Weight• Physical Exam• Airway Exam

Airway

Mallampati Classification

Airway

Class I

Facial pillars, soft palate, and uvula are visible

Airway

Class II

Facial pillars, soft palate, and part of the uvula

Airway

Class III

Soft Palate, and Base of Uvula

Airway

Class IV

Only soft palate is visibleIntubation is predicted to be difficult

Airway

Airway Evaluation

Thyromental distance not less than 3-4 finger width

Airway

Predictors of a difficult Airway:• Obesity• Mouth opening• Thyromental distance• Mental-hyoid distance• Retrognathia

Pre-operative Instructions

Why “NPO” Guidelines?

• To avoid aspiration pneumonia• To prevent foreign body obstruction

NPO Guidelines

Guidelines for pre-operative fasting

• No solids on day of surgery• Solids: 6—8 hours prior to surgery• Clear liquids: 2 hours prior to surgery• Oral Medications: 1 hour with sip of water

Equipments

IV Puncture

Butterfly Needles:

• Short metal needle • Easy to place• Winged tabs permit easy

securing point• Short needle reduces

patient anxiety

IV Puncture

Angiocatheter

• Indwelling peripheral catheter

• Catheter over needle• Needle serve as an

introducer• Variable length and gauges

of needles

IV Fluids

• IV Fluids provide hydration• Administration of

anesthetic agents and emergency medication

IV Fluids

Choose what you need and need what you choose

IV Puncture

The preferred site is:Antecubital fossaBrachial ArteryOther Sites: Hand, leg, neckThe hand is painful and somedrugs cause burning(e.g. diazepam, propafol)

Monitoring

•BP

•HR

•Pulse Oximetry

•RR

•3 Lead ECG

•End Tidal CO2

Monitoring

Definition: continuousobservation of data toevaluate physiologicFunction

Purpose: To permit promptrecognition of a deviationFrom normal, so correctivetherapy can beimplemented beforemorbidity ensures.

Monitoring

Respiratory Monitoring

1- Oxygen Monitoring

• Pulse Oximetry

Monitoring

2- Ventilatory Monitoring:

• Visual inspection (see the chest rise)

• Pretracheal Stethoscope (precordial)

• End-tidal CO2

Second Part

Drugs

Drugs

•No drug ever exerts a single action•No clinically useful drug is entirely devoid of

toxicity

Drugs

Ideal anesthetic agents for ambulatory general anesthesia:

• Rapid onset• Short duration of clinical effect• High clearance rate• Minimal tendency for drug accumulation

Benzodiazepines

• Most commonly used• Oral, IV, IM• The patient maintains his own reflexes• May cause respiratory depression in very large doses

Effects:• Sedation• Anxiolysis• Antigrade amnesia

• Diazepam (VALIUM)• Midazolam (VERSED)• Reversal: Flumazenil

Opioids

Alter the sensation and suppress responses associated with certainmanipulation (such as elevation of a tooth), which persist despiteachievement of a profound nerve block

Effects:• Analgesia

Types:• Fentanyl• Mepridine • Morphine • Reversal Naloxon (Narcan)

Anesthetic AgentsPropofol

• Dose dependant depression of the central nervous system that give rise to anesthetic effect that ranges from sedation to hypnosis

• Short acting

• Widely used in ambulatory general anesthesia

Anesthetic Agents Ketamine

• A dissociative anesthetic

• Pharmacological immobilization “chemical straight-jacket”

• Used as an adjunct to general anesthesia

Guedel’s Classification

• Stage of Analgesia• Stage of Delirium• Stage of Surgical Anesthesia• Respiratory Paralysis

Guedel’s Classification

• Stage of Analgesia• Stage of Delirium• Stage of Surgical Anesthesia• Respiratory Paralysis

Guedel’s Classification

Stage I: Analgesia

• Patient is wake and conscious but remains under the drug influence

• Respiration, eye movement and all protective reflexes are intact

• Patient will be ideally calm and cooperative• Light sedation

Guedel’s Classification

• Stage of Analgesia• Stage of Delirium• Stage of Surgical Anesthesia• Respiratory Paralysis

Guedel’s Classification

Stage II: Delirium

• CNS Depression is more pronounced

• Patient may briefly lose consciousness• Respiration may be irregular in early stage II• Pupils reactive to light• Increased skeletal muscle tone/activity• Laryngeal and pharyngeal reflexes increased

• Entry into stage II is undesirable• Patients will likely be hyper-responsive and difficult to manage

• During induction, stage II is typically bypassed

CONFUSION

Guedel’s Classification

• Stage of Analgesia• Stage of Delirium• Stage of Surgical Anesthesia• Respiratory Paralysis

Guedel’s Classification

Stage III: Surgical Anesthesia

• Desired level of anesthesia for major surgical procedures• Patient unconscious• No response to surgical stimulus (abdominal skin incision)• Respiration regular (autonomic and involuntary)• Alteration in muscle tone (relaxation)

Stage III is characterized by division into several (continuous) planesof anesthesia

Differences related to variance in:• Respiration• Eyeball movement• Reflexes• Papillary constriction

Stage III: Surgical Anesthesia

Not an appropriate level of anesthesia for office setting• Requires continuous respiratory support/ventilation • No protective reflexes

Patient will be unresponsive and unarousable• Potential for airway obstruction• Inability to react to adverse events

Potential exists to slide into stage IV with few outwardlyvisible signs unless carefully monitored

Guedel’s Classification

• Stage of Analgesia• Stage of Delirium• Stage of Surgical Anesthesia• Respiratory Paralysis

Stage IV: Respiratory Paralysis

• OK- NOW YOU ARE IN TROUBLE

• Onset of medullary depression

• Result in degradation of autonomic functions

• Begins with the onset of Respiratory Arrest

• Ends with Cardiovascular Collapse (late)

Conscious Sedation

• The patient maintain all reflexes

• The patient can respond to verbal command

• Drugs are titrated to effect

Ambulatory General Anesthesia

• Diazepam or Midazolam

• Fentanyl

• Propofol

• +/- Kitamine

Pediatric Cases

• Nitrous Oxide

Or

• Oral Midazolam

Or

• IM Ketamine

The End