Dental Hygienists - Sedation Overview

8/12/2019 Dental Hygienists - Sedation Overview

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Oral Sedation - A

Review



Review Description• Over view of legal environment

‣ Review ASA Health Classification

‣Individual Drugs

‣ Overview Oral Sedation Regimens

‣ Recovery

‣Appointment Framework

‣ Review NPO Guidelines

‣ Urgencies



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



Conflicts of InterestCommercial Support



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



ADA Guidelines

www.ada.org/sections/about/pdfs/anesthesia_ guidelines.pdf

http://www.ada.org/sections/about/pdfs/anesthesia_guidelines.pdf












Ohio Regulations

New York Regulations



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.



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.



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.



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





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



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?



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.



Medications

Over View

• Traditional agents - see Malamed



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.



Half-Life ?



Medications Specific

• Versed

• Demerol

• Phenergan

• Hydroxyzine

• Chloral Hydrate

• Halcion



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%



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



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



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



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%



Regimens

• Short

• Quadrant Dentistry

• Older Children / Quadrant Dentistry

• Older Children



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



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



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



Regimens

• Older Children

‣Halcion 0.25mg tablets x 2

‣Demerol 5-15mg tablets



Appointment

• Preop-assessment

Instructions

• Intraop

•Postop-assessment

Instructions



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.

http://www.emedicinehealth.com/script/main/art.asp?articlekey=5050

http://www.emedicinehealth.com/script/main/art.asp?articlekey=5050



NPO



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.



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.



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



NPO



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



Monitoring



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?



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



Monitoring/Documenta

tion Enteral/Enteral-Inhalation

• Patient Evaluation

• Pre-Operative Preparation

• Personnel

• Equipment

R ti P O



Routine PreOp

Monitoring• BP

• HR

• Hrhythm

• RR

• Temp

• Height

• Weight



Monitoring

• Direct Clinical Observation of the

Patient must occur• Oxygenation

• Ventilation

• Circulation

O ti



Oxygenation

• Color of Mucosa, Skin, Blood• Pulse Oximetry



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



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



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



99



95



90



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



Pulse Oximeter -

Errors• Low Pulse Amplitude

• Movement

• Anemia less than 10%

• Dyshemoglobins

• Carboxyhemoglobin

• Methemoglobin

• Sickle Cell Anemia

• Dyes, Electrocautery, Fingernail Polish, Skin

Pigment



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



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



Carbon Dioxide

Monitoring

• Infrared

• Endtidal Levels

• Wave Form



Respiratory Rate

Neonate 40

1yr 25

5yr 20

12yr 16

21yr 12



Circulation



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



Electrocardiography

• HR & Rhythm

• 12 / 5 / 3 lead



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



Pulse

• Newborn 120

•1yr 120

• 5yr 100

• 10yr 90



Blood Pressure

• 200/115 = ASA IV

• After administration of drug or changein rate of administration

• Automatic / Manual BP - w/wo

stethascope

• ! IV / SpO2



Common BP

• Newborn 80/45

•Infant 100/60

• Child 110/60

• Teenager 120/60



Temperature

• Not usually Critical

• Important to determine ± fever



CNS

• BIS - monitor

100 - wide awake

85-90 - eye opening 80 - amnesia

60 - likely to be unconscious, positive

amnesia

• 60 second lag



Monitoring Summary

• Oxygenation

• Color

• Mucosa, Skin, Blood

• Pulse Oximetry

• Ventilation

• Chest Excursions

• Auscultate Breath Sounds

• Capnography

• Circulation

• Blood Pressure

• Heart Rate

• Electrocardiography

• Temperature



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



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.



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



Personnel

• Conscious Sedation

• Operator + Surgical

Assistant/Monitor

• Deep Sedation/General Anesthesia• Operator, Surgical Assistant,

Dedicated Patient Monitor



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



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



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



Recovery

Aldrete Scoring



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



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



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)



Top 7 Emergencies

• syncope

• mild allergic reactions

• angina pectoris

• postural hypotension

• seizures

• bronchospasm

• hyperventilation

Critical Noninjectable



Critical Noninjectable

Drugs• Oxygen

• Vasodilator• Bronchodilator

• Antihypoglycemic

• Aspirin

Dental Hygienists - Sedation Overview

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