Sedation 33

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Thoughts on oral/sublingual

titration with triazolam

The prohibition of multiple dosing may have

unintended undesirable consequences Two smaller doses (2 x 0.25 mg) separated in time

are safer than one larger dose (1 x 0.5 mg)

Multiple dosing can prolong effect duration

Dose stacking can provide limited titration

Faster onset, reduced variables with sublingualtriazolam enhance titration ability

USP Workshop


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Safeguards for oral sedation

beyond anxiolysis Continual monitoring of patient for

consciousness Continuous monitoring of pulse oximetry,

heart rate

Continual monitoring of blood pressure

Use of reversal agent if patient drifts into

unconsciousness and cannot be aroused

AGD White Paper


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State Regulations for Adult

Oral Sedation


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Proposed Changes to ADA

Documents on Sedation ADA Policy Statement: The Use of Sedation and General

Anesthesia by Dentists

Housekeeping Guidelines for Teaching Pain Control and Sedation to

Dentists and Dental Students Major changes in definitions, teaching of moderate enteral

sedation

Guidelines for the Use of Sedation and General Anesthesiaby Dentists Major changes in definitions, performance of moderate enteral

sedation


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Proposed ADA Teaching

Guideline Changes Allows multiple dosing of triazolam up to 0.5 mg total dose

within definition of minimal sedation when full effect ofprevious dose known

Requires 16 hour course for minimal enteral sedation (mayinclude inhalation sedation as well)

Allows multiple dosing of triazolam beyond 0.5 mg withindefinition of moderate sedation

Requires 60 hour course for moderate enteral sedation toinclude management of 10 patients with IV access withfaculty/student ratio of 1/3


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Proposed ADA Use Guideline

Changes Requires dentist to be able to rescue patient whose level of

sedation becomes deeper than initially intended

Requires ACLS or appropriate dental sedation /anesthesiaemergency management course in addition to 60-hour coursefor oral moderate sedation

Requires time-oriented anesthesia record with vital signsrecorded continually


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Flumazenil

(Romazicon)

0.1 mg/mL

5 mL vials


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Flumazenil (2)

Specific benzodiazepine receptor antagonist

Causes rapid reversal of: Unconsciousness Sedation Amnesia Psychomotor dysfunction


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Flumazenil (3)

Most patients respond to dose of 0.6 - 1.0

mg IV Resedation most common after large doses

of benzodiazepine and long procedures

Monitor for up to 2 hr after administration


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Flumazenil (4)

Adverse effects Nausea and vomiting, agitation Seizures in patients with epilepsy

Drug interactions Benzodiazepine withdrawal

CNS stimulation with tricyclic antidepressants


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Questions regarding flumazenil

reversal

Rate of emergency progression with oral

triazolam Relative efficacies and onset times of

intravenous versus intramuscular, other

routes Safety of standard dosing versus titration


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Flumazenil effects: influence of

route of administration in dogs

Heniff et al:

Acad Emerg Med

4:1115-8, 1997.

Route Reversal time(sec)

IV 12025

SL 26295

IM 310134

Control 1620


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Comparison of 3 Routes of FlumazenilAdministration to Reverse Benzodiazepine-

induced Desaturation in an Animal Model

0.5 mg/kg midazolam IV to produce respiratorydepression (SaO2 to 90%) in anesthetized dogs

2 minutes later given reversal treatment No injection control 0.01 mg/kg (0.12-0.17 mg) IV flumazenil 0.2 mg SM flumazenil

0.2 mg IL flumazenil Blood drawn at various times for flumazenil

measurements

Unkel et al: Pediatr Dent 28:357-62, 2006


14/48 Unkel et al: Pediatr Dent 28:357-62, 2006



1 ?


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2402101801501

2

3

4

5

Tongue (n=5)IM (n=3)IV (n=2)

Observer Rating of Sedation Post Flumazenil (0.2 mg) Administration

Time (minutes post-1st SL triazolam dose)

Seda

tionScor

e

flumazeniladmin.

Jackson et al: unpublished data


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24021018015030

40

50

60

70

80

90

100

tongue (n=5)IM (n=3)

IV (n=2)

Bispectral Analysis Post Flumazenil (0.2 mg) Administration

time (minutes post-1st SL triazolam dose)

flumazeniladmin.



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2401801206000

20

40

60

80

100

#569#570#571#572#573#574#575#576#577

#578

Psychomotor Function Assessment10 Minutes Post-Flumazenil

Time (minutes)

DS

ST

Score

flumazenil(0.2 mg)

Flumazenil Admin:

Filled circles: IMFilled triangles: SLOpen squares: IV



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Rebound Sedation

at the Time of Discharge

Four subjects required an additional dose of flumazenil (0.2 mg, IV) 60 minutes

after the initial dose (as determined by the anesthesiologists discharge criteria):

IV: 1 subject IM: 1 subject SL: 2 subjects



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Lorazepam (Ativan)

Dosage forms: injection: 2 and 4 mg/mL in 1 and 10 mL

vials and 1 mL Tubex; tablets: 0.5 , 1, and 2 mg

Directions: IV, 1-2 mg at start of case; oral, 2 (1-4) mg 1hr before bedtime or 2 hr before treatment

Children: not recommended

Clinical duration: 6 hr

Recommendation: use for prolonged procedures or whentreatment is delayed


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Cardiac Disease and Dental

Treatment

AHA/ACC Task Force on Perioperative

Evaluation of Cardiac Patients UndergoingNoncardiac Surgery

Dental treatment and hypertension


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AHA/ACC Task Force on PerioperativeEvaluation of Cardiac Patients

Undergoing Noncardiac Surgery

Operating roomYes

YesOperating room

Postoperative riskstratification and riskfactor management

Major Intermediate Minor

Clinical predictors

Recent favorable coronaryangiogram or stress test

Coronary revascularization with 5 yrand no recurrent symptoms or signs

Need for noncardiac surgery


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Estimated energy requirements for

various activities

1 MET Normal daily household activities

Walk a block on level ground at 2-3 mph

4 METs Climb flight of stairs

Walk on level ground at 4 mph

Heavy housework or moderate exercise (golf,doubles tennis, bowling, dancing)

>10 METs Participate in strenuous sports (swimming, singlestennis, football, basketball, skiing)


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AHA/ACC Task Force on PerioperativeEvaluation of Cardiac Patients Undergoing

Noncardiac Surgery (2)

Major clinical predictors:

Unstable coronary syndromesDecompensated CHFSignificant arrhythmiasSevere valvular diseaseRecent MI with important ischemic riskUnstable or severe angina

Medical managementand risk factor reduction

Consider delay orcancel surgery

Care dictated by findingsand treatment results

Consider coronaryangiography

Major clinical predictors

We dont

treat these


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Intermediate clinical predictors:

Mild angina pectorisPrior MICompensated or prior CHF

Diabetes mellitus



Noninvasive testing

4 METs and intermediatesurgical risk or low surgical risk

Intermediate clinical predictors

Low risk

We may have

to consult

physician re

these patients


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Minor clinical predictors:

Advanced ageAbnormal ECGNonsignificant arrhythmiaLow functional capacity

History of strokeUncontrolled systemic hypertension



Noninvasive testing

4 METs or intermediateor low surgical risk

Mild clinical predictors

Low risk

We often dont

have to

consult

physician re

these patients


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Dental treatment and

hypertension SBP DBP MRF Recommendation

120-139 80-89 Yes/no Routine dental care OK; discuss BP guidelines

140-159 90-99 Yes/no Routine dental care OK; consider stress reduction

protocol; refer for medical consult

160-179 100-109 No Routine dental care OK; consider stress reductionprotocol; refer for medical consult

160-179 100-109 Yes Urgent dental care OK; refer for medical consult

180-209 110-119 No No dental treatment without medical consult; refer

for prompt medical consult

180-209 110-119 Yes No dental treatment; refer for emergency medicaltreatment

210 120 Yes/no No dental treatment; refer for emergency medicaltreatment

MRF: medical risk factor (e.g., history of MI, angina, high coronary disease risk,recurrent stroke prevention, diabetes mellitus, renal disease.

From Merin RL: JADA 135:1220, 2004; after Herman et al: JADA 135:576-84, 2004.


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Obesity and sedation

Two thirds of the adult population in the

U.S. are obese or overweight 17% of children ages 2 to 19 yrs are

overweight

Prevalence has tripled in the past 2 decades

Obesity is a leading cause of restrictive lung

disease


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Body mass index

BMI =BMI =

[Weight (kg)][Weight (kg)]

[Height (m)][Height (m)]22

Ex = = 24.9Ex = = 24.9

[89 kg][89 kg]

[1.89 m][1.89 m]22

>25 overweight; 30 obese; 40 morbidly obese


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OverweightOverweight

InIn

childrenchildren


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Dynamic lung volumes


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Recognition of Potential Airway

Difficulty

Mallampati-Samsoon classification

Thyromental distance

Joint mobility

Head and neck frontal and profile views Tonsilar separation/obstruction


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Mallampati-Samsoon

classification of the airway

Class I - uvula, faucial pillars, soft palate

Class II - faucial pillars, soft palate

Class III - soft palate

Class IV - hard palate


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Mallampati-Samsoon Airway ClassificationMallampati-Samsoon Airway Classification


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Facial anomalies

Maxillary hypoplasia

Aperts syndrome Crouzons syndrome

Coronal craniosynostosis (Saethre-Chotzen

syndrome) Rubenstein-Taybi syndrome


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Facial anomalies (2)

Mandibular hypoplasia

Treacher Collins syndrome Hemifacial microsomia (Goldenhars

syndrome)

Moebius syndrome (micrognathia 2O to

neuromuscular deficit) De Lange syndrome

Robin sequence


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Sleep apnea

Obstructive sleep apnea is most common

Drugs with muscle relaxant properties can cause

loss of airway

Drugs with respiratory depressant properties can

cause loss of respiration

Sleep deprivation can increase chance foroversedation

Need for extended monitoring


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Sleep apnea (2)

Repetitive episodes of upper airway obstruction

during sleep

Accompanied by sleep disruption, hypoxemia,

hypercarbia, cardiovascular stimulation

Often seen in obese or in patients with tonsillar

hyhpertrophy or craniofacial abnormalities Secondary cardiac and lung abnormalities

Do you want to treat thesepatients?


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Sleep apnea (3)

Most patients undiagnosed

Good questions to ask

Do you snore nightly? Has anyone ever said that you stop breathing in your sleep? Do you feel tired and groggy on awakening? Do you fall asleep easily during the day?

Do you frequently have headaches in the morning? Consider recommending sleep study for patients with

positive findings


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Sedation 33

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Transcript of Sedation 33