concious sedation

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CONSCIOUS SEDATION Submitted by: Swati Markandey Ashish Arya Department of Pedodontics Govt. College of Dentistry, indore

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Page 1: Concious Sedation

CONSCIOUS SEDATION

Submitted by:Swati MarkandeyAshish Arya

Department of PedodonticsGovt. College of Dentistry, indore

Page 2: Concious Sedation

CONTENTS Introduction Behaviour management Definition Levels of sedation Objectives Indications Contraindications Conscious sedation in children Prerequisite Patient assessment and preparation Sedation techniques Nitrous oxide and oxygen sedation

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INTRODUCTION To perform the

highest quality dental care in pediatric patients, the practitioner may need to use pharmacologic means to obtain a quiet, cooperative patient.

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BEHAVIOR MANAGEMENT Definition: It is defined as means by which the

dental health team effectively and efficiently performs dental treatment and thereby instils a positive dental attitude. (Wright,1975)

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Behaviour Management

Non-pharmacologica

l approach

Communication

Behaviour shaping

Behaviour management

Pharmacological approach

Premedication

Conscious sedation

General anaesthesia

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DEFINITIONA minimally depressed level of consciousness,

that retains the patient’s ability to maintain an airway independently & respond appropriately to physical stimulation & verbal commands.

(AMERICAN DENTAL

ASSOCIATION,1993)

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LEVELS OF SEDATION Sedation/analgesia is defined by a continuum of “levels”

ranging from minimally impaired consciousness to unconsciousness.

The following terminology refers to the different levels of sedation intended by the practitioner

Remember: Levels of sedation are considered to be on a continuum because a sedated child can go in and out of an intended level quite rapidly.

Minimum sedation

Moderate sedation

Dissociative

sedationDeep

sedationGeneral

anaesthesia

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MINIMAL SEDATION (ANXIOLYSIS)

A drug-induced state during which Patients respond normally to verbal commands. Cognitive function & coordination may be

impaired. Ventilatory and cardiovascular functions are

unaffected. Note: This level is rarely adequate for an infant

or young child undergoing sedation for a procedure.

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MODERATE SEDATIONA drug-induced depression of consciousness during which

Patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation.

Airway is patent, & spontaneous ventilation is adequate.

Cardiovascular function is usually maintained.

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DISSOCIATIVE SEDATION

(Ketamine) A cataleptic state occurs with both profound analgesia and amnesia while maintaining protective airway reflexes, spontaneous respirations, and cardiopulmonary stability.

NOTE: Due to Ketamine’s markedly different clinical effect, it does not officially fit ASA sedation continuum. However it is generally recognized to produce a level of sedation between moderate and deep sedation.

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DEEP SEDATIONA drug induced depression of consciousness

during which Patients cannot be easily aroused but respond

purposefully after repeated verbal or painful stimulation.

The ability to independently maintain ventilatory function, may be impaired.

Patients may require assistance in maintaining a patent airway.

Cardiovascular function is usually maintained. A state of deep sedation may be accompanied

by partial or complete loss of protective airway reflexes.

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GENERAL ANESTHESIA A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation.

The ability to independently maintain ventilatory function is often impaired.

Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function.

Cardiovascular function may be impaired.

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Conscious sedation General anaesthesia

Patient is cooperative , but anxious and fearful

Patient is uncooperative

Generally no extensive investigations are required

At least basic investigations are must.

No premedication is required Premedication is required

Patient is conscious and contact is maintained

Patient is unconscious.

Airway is maintained Ventilation is required

NPO not required NPO strict

Recuperation period is 1-2 minutes

Time consuming procedure

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OBJECTIVESBenett (1978) has stated the objectives to be: The patient’s mood should be altered. Child’s pain threshold should be increased. Amnesia should occur. Patient should be cooperative. Patient should be conscious, respond to verbal

stimuli. All protective reflexes are intact. Vital signs stable and normal.

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INDICATIONS Dental anxiety and phobia Prolonged or traumatic dental procedures Medical conditions potentially aggravated by

stress Medical conditions affecting the patient’s

ability to cooperate Patient lacking cooperation because of lack of

psychological or emotional maturity Special needs

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CONTRAINDICATIONS Chronic obstructive pulmonary disease

(COPD), epilepsy, & bleeding disorders. Uncooperative or unwilling patients. Unaccompanied patients.. Prolonged surgery. Lack of equipment or inadequate personnel.

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CONSCIOUS SEDATION IN CHILDREN

Children receive sedation more frequently than adults

To meet the necessary goals sedation/analgesia must be deeper than adults

Child can easily slip from one sedation level to another

Anatomical and physiological differences exist between children and adults

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ANATOMIC & PHYSIOLOGICAL DIFFERENCES IN

CHILDREN Differences in basal metabolic rate Difference in respiratory rate Airway management Reduced tolerance to respiratory obstruction. Cardiovascular parameters are different

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PREREQUISITES FOR CONSCIOUS SEDATION Knowledge of the agents to be used Consent No lack of equipment Planned rationale for use of sedation

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PATIENT ASSESSMENT & PREPARATION

Obtaining patient history & information. Age, weight, heightHealth historySystems review Airway evaluation ASA Physical Status Classification Instructions to parents preop & postop. Adequate documentation of the sedation

experience with monitoring of vital signs.

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PREPARATION FOR SEDATION PROCEDURES

SUCTION FUNCTIONING SUCTION APPARATUS

OXYGEN ADEQUATE OXYGEN SUPPLY & FLOWMETERS TO ALLOW ITS DELIVERY

AIRWAY APPROPRIATE AIRWAY (ENDOTRACHEAL TUBES, FACE MASK)

PHARMACY

ALL BASIC DRUDS NEEDED TO SUPPORT LIFE DURING AN EMERGENCY

MONITORS

FUNCTIONING PULSE OXIMETER

EQUIPMENT

SPECIAL EQUIPMENT OR DRUGS FOR A PARTICULAR CASE (E.G. DEFIBRILLATOR)

( AAP/ AAPD GUIDELINES , 2006)

The acronym “SOAPME” offers a routine for preparing for

sedation.

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SEDATION TECHNIQUES

Inhalation sedation Oral sedation Intramuscular sedation Intravenous sedation Rectal sedation Submucosal sedation

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INHALATIONName of agent

Dose Indications and benefits

Limitations and risks

Nitrous oxide •Used for mild to moderate levels of anxiety•Rapid onset, early elimination and recovery•Duration of action can be controlled

•Agent has weak potency•Not used in children with severe behaviour problems•Cannot be used in claustrophobic patients, respiratory tract infections

Desflurane Inhaled concentration should be 6-8%

•Rapid induction of anaesthesia and rapid emergence•Produces direct skeletal muscle relaxation•No hepatotoxicity and no nephrotoxicity

•Irritating to airway in awake patients•Result in transient tachycardia•Concentration dependent increase in respiratory rate and decrease in tidal volume

Sevoflurane Inhaled concentration should be 2-4%

•Non irritating to airway •Does not produce tachycardia•No heapatotoxicity

•Hypotension and decrease in cardiac output•Concentration dependent increase in respiratory rate and decrease in tidal volume•Renal injuries and renal impairment have been reported

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ORALName of agent

Dose Indications and benefits

Limitations and risks

Hydroxyzine 1-2mg/kg •Mild sedative along with antiemetic and anticholinergic action•Potentiate narcotic and CNS depressant

•Better used in combination with other drugs•Adverse reaction in form of extreme drowsiness and dry mouth , hypersensitivity

Promethazine 0.5-1.1mg/kg •With sedative and antihistaminic properties•Potentiate other CNS depressant

•Better used in combination with other drugs•For mild level of anxiety only•To be used with caution in children with history of asthma and sleep apnoea•Should be avoided in seizure prone patients

Diazepam 0.2-0.5mg/kg To a maximum dose of 10mg

•Safe agent for mild to moderate anxiety particularly in children with cerebral palsy, mental retardation•Children less than 6 years of age

•Not effective in severe anxiety when used alone•Common adverse reaction in form of ataxia and prolonged CNS effect

Meperidine 1-2.2mg/kg Best used in combination with other agent

•Poor oral absorption•Should be used with extreme caution in patients with hepatic/ renal diseases or history of seizures

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INTRAMUSCULARName of agent Dose Indications

and benefitsLimitations and risks

Ketamine 10 and 50mg/ml

Dissociative anaesthesia

Midazolam 1 and 5 mg/ml •Possesses hypnotic, anticonvulsant, muscle relaxant properties as well as being antegrade amnesic and anxiolytic

•Little data for effective dose in paediatric context•Used mainly for short procedure

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INTRAVENOUSName of agent Dose Indications

and benefitsLimitations and risks

Propofol 2mg/kg bolus iv for induction9mg/kg for maintenance

•Suited for outpatient surgeries as incidence of postoperative nausea and vomiting is low

•Respiratory depression

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NITROUS OXIDE & OXYGEN SEDATION

DESIRABLE CHARACTERSTICS OF N2O/O2 SEDATION:

Analgesic Properties (Pain Control) Amnestic properties Anxiolytic properties (sedative effects) Onset of Action Recovery Elimination Acceptance

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PHARMACOKINETICS

It quickly agent crosses the pulmonary membrane & enters the blood stream.

It is an insoluble drug & remains unchanged in blood & does not combine with any blood elements.

Since N2O does not break down, so peak clinical effects may be seen within 3-5 minutes.

There is no biotransformation & 99% of gas is rapidly eliminated by the lungs.

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PHARMACODYNAMICS It produces nonspecific CNS depression. At concentrations 30-50%, N2O will produce a

relaxed & dissociated patient who is easily susceptible to suggestion.

Moderate sedation is achieved when N2O concentration is 50% .

At concentrations greater than 60%, patients may experience discoordination, ataxia, giddiness, and increased sleepiness.

Concentrations greater than 50% are not to be used in dental practice.

The gas is non-irritating to the respiratory tract .

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Nitrous oxide is a good analgesic, even 20% produces analgesia equivalent to that produced by conventional doses of morphine.

A mixture of 70% N2O+25-30% O2+0.2-2% another potent anesthetic is employed for most surgical procedure.

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ARMAMENTARIUM The Central Storage System The nitrous oxide tanks are always marked

blue for identification, and the oxygen tanks are green.

Nitrous Oxide-Oxygen Machine Breathing Apparatus Nasal hood Safety Features

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Schematic diagram to show components of a N2O/O2

delivery & scavenging system

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A-Poorly fitting mask with leakage under nares.B-Well -fitting mask.

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•Bag is filled with 100% oxygen and delivered to the patient for 2/3 minutes at an appropriate flow rate of 5-6 L /minute.•Once the proper flow rate is achieved, the N2O can be introduced by slowly increasing the concentration at increments of 10% to 20% to achieve the desired level.

•SENSATIONS- Felt are floating, giddy feeling with tingling of digits. The eyes will take on a distant gaze with sagging eyelids.

TECHNIQUE

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TECHNIQUE When this state is reached, the local anaesthetic may

be given. Once this is completed, the concentration can be reduced to 30% nitrous oxide and 70% oxygen or lower. The patient can now be maintained and monitored & procedure carried out.

Recovery can be achieved quickly by reverse titration. Once the sedation is reversed, the patient should be allowed to breathe 100% oxygen for 3-5 minutes.

The patient should be allowed to sit. Even though psychomotor effects return to normal within 5 to 15 minutes, it is not advisable to allow teenage patients to drive themselves.

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STAGES OF ANESTHESIA Plane 1:Moderate sedation and Analgesia Achieved with concentration of 5-25%N2O Plane 2: Dissociation sedation and analgesia Concentration of 25-45% N2O Plane 3: Total anaesthesia Achieved with 45-65% concentration Lightest planeSomnolent stateDeepest plane Plane4

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ADVERSE EFFECTS AND TOXICITY

Nausea and vomiting Middle ear pressure can increase pain in

patients with acute otitis media. Neurotoxicity, renal/liver toxicity. The greatest concern regarding toxicity centres

on exposure of dental personnel to high ambient air levels of the gas during its use for patient sedation (i.e. longer than 3 hours per week

Diffusion hypoxia

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REFERENCES DENTISTRY FOR THE CHILD &

ADOLESCENT; 9th edition; R E McDonald, D R Avery, J A Dean.

TEXTBOOK OF PEDODONTICS; 2nd edition; Shobha Tandon

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THANK U!