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Relaxed, But Not Asleep: How to use Nitrous Oxide or Oral Benzodiazepines for Effective Minimal Sedation

Dr. Carilynne Yarascavitch BSc DDS MSc (Dental Anaes) Dip ADBA

[email protected]

David After Dentist

Dangers in the Dental Office Purpose

§  Refresher for those practicing sedation §  Primer for those interested §  Technique Tips §  Regulatory Landscape

What kind of sedation?

§  Minimal Sedation §  Adults

Focus

§  RCDSO Compliance – Framework for this session

§  “Practice Ready” – Practice tips to be prepared for patients

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Confidence is the feeling you have before you understand the situation. Play safe.

Objectives

§  At the end of this session, attendees will be able to: 1.  Identify the clinical signs which distinguish

minimal from moderate sedation. 2.  Select patients, drugs, and doses suitable for

the goal of minimal sedation. 3.  Establish policies and practices in their office

which comply with RCDSO regulations.

Objective 1

Identify the clinical signs which distinguish minimal from moderate sedation.

What is “Sedation” ?

§  Sedation – Suppression of arousal and behaviour – Decrease in activity

§  Anxiolysis – Ability to decrease anxiety

§  Amnesia – Ability to impair memory

§  Hypnosis – Ability to produce drowsiness and facilitate

onset and maintenance of sleep

Continuum Depth of Sedation

Clinical Effect Minimal ðModerate ðDeep ðGA

Sedation Anxiolysis Amnesia Hypnosis

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Minimal vs Moderate Sedation

§  Minimal sedation – Sedation, anxiolysis

• amnesia – Comfortable and relaxed – May experience natural sleep – Conscious at all times – Respond purposefully to

verbal and tactile simulation

Minimal vs Moderate Sedation

§  Moderate sedation – Sedation, anxiolysis

• amnesia, MILD hypnosis – Comfortable and relaxed – May be drowsy – Conscious at all times – Respond purposefully to repeated

verbal and tactile stimulation

§ Use of Sedation and General Anaesthesia In Dental Practice (Approved by Council June 2012)

§ Minimal standards for the use of sedation

RCDSO Standards of Practice Overview Guidelines to Standards of Practice

§  Older “Guidelines”: Definitions of sedation combine route of administration with depth – “Oral conscious sedation”

§  2012 “Standards of Practice”: RCDSO revisions demphasize route of administration and emphasize depth (clinical effect) independent of route of administration – “Minimal, Moderate, Deep”

Conscious Sedation “…a minimally to moderately depressed level

of consciousness that retains the patient’s ability to independently and continuously

maintain an airway and respond appropriately to physical stimulation and

verbal command.”

Minimal Sedation “…responds normally to tactile

stimulation and verbal commands. Although cognitive function and coordination may be modestly

impaired, ventilatory and cardiovascular functions are

unaffected.”

Moderate Sedation “…responses purposefully to verbal commands, either alone or by light tactile stimulation. No interventions are required to maintain a patient

airway and spontaneous ventilation is adequate. Cardiovascular function is

usually maintained.”

RCDSO Standards of Practice Part I – Conscious Sedation RCDSO Standards of Practice

§  If we define level of sedation by clinical effect, does route of administration matter? –  Yes. –  Route matters for facility permits and

provider registration because the RCDSO makes assumptions about sedation depth based on •  the route you use** •  the doses you provide**

**more on this later

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How do I know if I am doing minimal or moderate? 1)  Clinically by assessing the patients level

of consciousness using response to voice/touch

–  Immediate – minimal –  Repeated – moderate

2) Artificially by route as defined by our RCDSO regulator* – Multiple oral drugs –  IV = moderate

**more on this later

RCDSO Appendix III Characteristics of the Levels of Sedation

MINIMAL SEDATION

MODERATE SEDATION

DEEP SEDATION

GENERAL ANAESTHESIA

CONSCIOUSNESS Maintained Maintained Reduced Unconscious

RESPONSIVENESS To either verbal or

tactile

May require one or both verbal

and tactile

Response to repeated or

painful stimuli

Unrouseable, even to pain

AIRWAY Maintained No intervention required

Intervention may be required

Intervention usually required

PROTECTIVE REFLEXES Intact Intact Partial loss Assume absent

SPONTANEOUS VENTILATION Unaffected Adequate May be

inadequate May be

impaired

CARDIOVASCULAR FUNCTION Unaffected Usually

maintained Usually

maintained May be

impaired REQUIRED

MONITORING Basic Increased Advanced advanced

Differential Diagnosis Characteristics of the Levels of Sedation

MINIMAL SEDATION

MODERATE SEDATION

DEEP SEDATION

GENERAL ANAESTHESIA

HOW DO THEY RESPOND?

Voice OR Touch?

Voice AND touch?

REPEATED voice and touch

or PAIN?

NO RESPONSE

AIRWAY No change NO SUPPORT required

SUPPORT required:

Head tilt, chin lift

Intervention required

BREATHING No change SOMETIMES

Slower, smaller breaths

USUALLY Slower, smaller

breaths

Slowest, smallest or NO

breaths

CIRCULATION No change Small changes Moderate changes Big changes

PATIENT MONITORING Basic Increased EXPERT EXPERT

How do they respond? Verbal Indicators of Depth of Sedation

§  Immediate answers §  Speech is clear §  Speech makes sense §  Delayed answers §  Nonsensical responses §  Incoherent speech §  No response

Levels of Sedation

Scenario Effect Clinically Legally 69 yo F 50 kg ASA II Triazolam 0.125 mg

•  Responds to light touch

•  No snoring •  RR10, HR 80

BP 120/80

Minimal Minimal

69 yo F 50 kg ASA II Midazolam 1 mg IV

•  Responds to voice

•  RR8, HR 70 BP 110/72

Minimal Moderate

Levels of Sedation

Scenario Effect Clinically Legally 35 yo F 50 kg ASA II Triazolam 0.5 mg

•  No response to voice, but responds if touched

•  Snoring sound

Moderate Moderate

35 yo F 50 kg ASA II Triazolam 0.5 mg

•  Groans if pinched •  Snoring when you

lift chin, no sound if you don’t

Deep !

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What depth of Sedation?

§  18 yo F 72 kg ASA II §  Triazolam 0.375 mg §  Pre-op VS: BP 128/68, HR 79, RR 12

§  Tap lightly on the shoulder for verbal response §  Respond normally to your questions §  Light snoring when not stimulated §  Relaxed breathing §  BP 130/70, HR 75, RR 12

§  Minimal Sedation



§  Responds when you touch and call their name §  Response is slow §  Speech is slurred but answers may sense §  Loud snoring when not stimulated §  BP 120/80, HR 70, RR 8

§  Moderate Sedation



§  Pinching shoulder causes movement §  Heavy snoring unless chin is lifted §  Belly is tense and moves strangely without chin lift §  BP 110/60, HR 72, RR 9

§  Deep Sedation



§  Responds when you call their name §  Response is normal with clear speech §  Quiet breathing §  BP 120/80, HR 70, RR 10

§  Minimal Sedation



§  No response to name, no response with jaw thrust §  No breath sounds unless jaw is thrusted upward §  Relaxed belly that doesn’t appear to be moving much §  BP 90/60, HR 90, RR 6

§  General Anaesthesia

Objective 2

Select patients, drugs, and doses suitable for the goal of minimal sedation.

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Patient Selection

§  Sedation techniques – “are to be used only when indicated, as an

adjunct to appropriate non-pharmacological means of patient management” p.2

RCDSO Standards of Practice General Standards

Indication for Sedation

§  Fear or Anxiety §  Poor Cooperation

– Mentally Challenged – Cognitively Impaired – Motor Dysfunction – Gag Reflex

§  Extensive Procedure

§  Document it!

§  “Adequate, clearly recorded current medical history” (#4, p.2) – present and past illnesses – hospital admissions – current medications – non-prescription drugs – herbal supplements – allergies

RCDSO Standards of Practice Professional Responsibilities

§  “Adequate, clearly recorded current medical history” (#4, p.2) – Functional inquiry* – Physician consult for medically

compromised patients – Reviewed for changes at each sedation

appointment


§  “Core medical history” – Must elicit the core medical information to

enable the dentist to assign the correct ASA Classification

– Should be system-based review of past and current health status (see RCDSO’s sample medical history questionnaire)

– Supplemented with questions relevant to the use of sedation

RCDSO Standards of Practice Appendix I

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Functional Inquiry

§  Investigates potential concerns from the medical history.

§  Your functional inquiry should include a review of systems affected, and notations on any investigations.

§  The goal is to ask questions which help you to assess severity and stability, in order to form an impression of the effect of systemic disease on the patient’s health and potential impact on treatment.

Functional Inquiry

§  What is/are the diagnosis/diagnoses? –  Estimate date of diagnosis or initial presentation

§  What underlying body systems does it affect? –  Review the body system for sign/symptoms of disease

§  Do you need more information? –  Gather investigations such as chairside tests e.g. blood

glucose, medical letters §  What is your impression of the severity/stability?

–  Ask questions to determine effects on the body systems and disease progression, limitations in daily function, and changes in quality of life

Functional Inquiry Review of Systems §  CNS – central nervous system: epilepsy, stroke, TIA §  CVS – cardiovascular: hypertension, coronary artery

disease §  RESP – respiratory: asthma, COPD §  DERM – dermatological: eczema §  ENDO – endocrine: diabetes, thyroid §  GI – gastrointestinal: liver, HEPATIC §  GU – genitourinary: kidney, RENAL §  HEME – hematological: bleeding disorders, anemia §  MSK – musculoskeletal: joint replacement, arthritis, osteoporosis §  PSYCH – psychological: depression, bipolar disorder, anxiety disorder §  SH – modifiable lifestyle factors: smoking, alcohol, recreational drugs

General Review of Systems Important for any disease process §  Precise medical condition

–  Estimated date of diagnosis §  How is this condition managed?

–  Medications? Diet? Surgery? –  No intervention (observation only)?

§  Follow-up medical care –  Does the patient see their MD or specialist for this

condition? –  How often? –  Last seen? –  What was MD’s last recommendation?

General Review of Systems Important for any disease process §  Symptoms patient experiences

–  Does the patient have symptoms? –  What are the symptoms?, When do they occur?, –  When did they last occur?, What about the time

before last? •  Asking for both most recent and the previous time allows

better estimation of frequency of events, which can help determine stability.

§  Has this condition ever required hospitalization? §  Effect on daily life

–  Can the patient engage in normal activities or do they have to reduce or change activities because of their disease?

§  “A determination of the patient’s American Society of Anesthesiologists (ASA) Physical Status Classification as well as consideration of any other factors that may after his/her suitability for sedation must be made prior to its administration.” (#5, p.2) – #1 other factor to consider: Sleep Apnea


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ASA Physical Status Classification System

I A normal healthy patient II A patient with mild systemic disease III A patient with severe systemic disease IV A patient with severe systemic disease that is a

constant threat to life V A moribund patient who is not expected to survive

without the operation E A declared brain-dead patient whose organs are

being removed for donor purposes

ASA Status: Asthma

§  Uses puffer daily, last asthma attack 2 years ago – ASA II

§  Active wheezing with expiration, difficulty breathing – ASA IV

§  Uses puffer daily, last asthma attack 1 week ago, FEV1 consistently < 80% baseline – ASA III

ASA Status: CAD

§  HTN, obese, severe chest pain at rest yesterday, extreme SOB with minimal exertion 2 days ago – ASA IV

§  HTN, obese, SOB climbing 3 stairs, takes breaks – ASA III

§  HTN, 20 pack-year smoker, runs daily – ASA II

§  “Core Physical Examination” – Current basic physical examination – General appearance, noting abnormalities – Taking and recording of vital signs i.e.

heart rate and blood pressure – Appropriate airway assessment

RCDSO Standards of Practice Appendix I

Basic Physical Exam Heart Rate §  Heart Rate = # beats/min §  Normal Resting HR (Adults)

–  60 to 100 bpm

§  Bradycardia –  < 60 bpm

§  Tachycardia –  > 100 bpm

Basic Physical Exam Blood Pressure For a patient without a pre-existing diagnosis:

–  Normal Blood Pressure •  120/80

–  Prehypertension •  120-139/80-89

–  Hypertension •  >140/90

For a patient diagnosed with hypertension, targets: –  <140/90 –  <130/80 for Diabetics, Renal disease

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Basic Physical Exam Respiratory Rate §  Respiratory Rate = # breaths/min

§  Normal Respiratory Rate (Adults) –  8-12 breaths/min

§  Tachypnea –  > 12 breaths/min

§  Bradypnea –  < 8 breaths/min

§  Respiratory Arrest –  0 breaths/min

Functional Inquiry Example 1

50 year-old M for periodontal treatment. Appears healthy and well-nourished, Ht 176 cm, Wt 70 kg BMI=22.6 (healthy wt). Dentally anxious (4/5). BP 110/70, HR 76. §  CVS: HTN (Diagnosed 2004) §  ROS: Treated with medication Zestoretic, pt compliant with

medication §  Pt denies SOB, CP, SOA, palpitations, TIA/Stroke. Daily exercise

30 min run 3x/wk. §  INV: MD letter March 2013 “well controlled” §  IMP: Mild, stable HTN §  ASA: II


45 year old F prosthodontic needs, anxious regarding dental treatment (3/5). Ht is 155 cm, Wt 70 kg, BMI=29.1 (overweight). Appears healthy/active. BP 140/75 HR 98. §  ENDO: DM2 (Diagnosed 15 yrs ago) §  ROS: Meds: Metformin and Glyburide, pt does not always

remember to take. Hospitalized 1x 10 yrs ago hypoglycemic attack with seizure, no sequelae; last hypoglycemic episode 3 months ago “felt dizzy”, took oral carbohydrate, “felt fine after”, no episodes since. Complications: retinopathy, numbness in feet, followed by TGH endocrinologist Dr. Barry q3 months.

§  INV: Blood sugar ranges 9-12 mmol/L; HbA1c 10.4, MD reports “poorly controlled” (MD letter Dec 13)

§  IMP: Pt has complications – mod severity; Pt has hypoglycemic episodes and poor blood sugar control - stability questionable.


45 year old F prosthodontic needs, anxious regarding dental treatment (3/5). Ht is 155 cm, Wt 70 kg, BMI=29.1 (overweight). Appears healthy/active. BP 140/75 HR 98. §  CVS: HTN and hyperlipidemia (Dx approximately June 2012) §  ROS: Treated with Coversyl and Atorvastatin, SOB with heavy

exercise, denies angina, palpitations, SOA, TIA/stroke, no hospitalizations. Can walk 2 flights stairs without stopping.

§  INV: MD letter Dec 13 BP 144/84 “poor control” §  IMP: Target BP for diabetes should be <130/80; pt has

inadequate risk reduction for MI/Stroke.

§  Summary IMP: Poorly controlled DM2 and HTN with questionable stability

§  ASA II +? ASA III?

Functional Inquiry

§  Core Functional Inquiry for Sedation

§  Respiratory System §  Cardiovascular System §  AIRWAY

Functional Inquiry “Airway” 2 Must-ask Questions: 1.  Are the nares patent? 2.  Any diagnosis of sleep apnea? 1 “Maybe” Question: 3.  Malampatti view

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UPPER AIRWAY ANATOMY Functional Inquiry “Airway” §  In the conscious state,

–  Tonic and reflex inspiratory activity in the genioglossus keeps the tongue away from the posterior pharyngeal wall

–  Tonic activity in the levator palati, tensor palati, palatopharyngeus and palatoglossus prevents the soft palate from falling back against the posterior pharynx

Obstruction by the tongue and epiglottis.

. Circulation 2000;102:I-22-I-59

Copyright © American Heart Association, Inc. All rights reserved.

STOP-BANG Questionnaire (Chung et al, 2008) Obstructive Sleep Apnea Screening Please answer the following questions to the best of your ability. Yes No S Do you snore loudly (louder than talking or loud enough to hear

through a closed door?) T Do you often feel tired, fatigued, or sleepy during the daytime? O Has anyone observed you stop breathing during your sleep? P Do you have or are you being treated for high blood pressure? For Doctor’s Use. B BMI >35 kg/m2

A Age >50 years N Neck circumference >40 cm G Gender M

2 STOP + 2 BANG – high risk sleep apnea - DO NOT TREAT 2 STOP + 1 BANG – possible sleep apnea 2 STOP + 0 BANG – low risk sleep apnea

Mallampati Classification §  Popular predictor for difficult airway management (modified by Samsoon & Young 1987) is a

§  Basis: visibility of oral & pharyngeal structures with paEent siFng in upright posiEon, mouth fully opened, tongue fully extended, without phonaEon

§  I & II: Easy §  III & IV Difficult

Malampati Classification

§  I & II = easy airway §  III & IV = difficult

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Functional Inquiry “Airway” 2 Must-ask Questions: 1.  Are the nares patent?

–  Delivery of nitrous oxide, supplemental oxygen

2.  Any diagnosis of sleep apnea? –  Relative contraindication to minimal sedation –  Nitrous oxide best choice

1 “Maybe” Question: 3.  Malampatti view

•  Class IV may be difficult to rescue from over-sedation

Drug Selection

How do I know if I am doing minimal or moderate? 1)  Clinically by assessing the patients level

of consciousness using response to voice/touch

–  Immediate – minimal –  Repeated – moderate

2) Artificially by route as defined by our RCDSO regulator* – Multiple oral drugs –  IV = moderate *more on this now

§  Specific standards for particular modalities 1.  N2O 2.  Oral single sedative drug 3.  Oral single sedative drug + N2O 4.  Oral multiple sedative drugs (+/- N2O) 5.  Parenteral (IV) 6.  Deep Sedation

RCDSO Standards of Practice Overview

1.  Administration of nitrous oxide and oxygen ALONE

2.  Oral administration of a SINGLE sedative drug

3. Combination of 1 & 2 –  IF minimal sedation is your intent –  AND symptoms reflect an effect of

minimal sedation

What modalities are considered by the RCDSO to produce minimal sedation?

1.  Oral administration of multiple sedative drugs

2.  Administration of a sedative drug (s) by any parenteral route:

•  Intravenous •  Intramuscular •  Subcutaneous •  Submucosal •  Intranasal

What modalities are considered are by the RCDSO to produce moderate sedation?

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Sedation Medications

Route/Modality Onset Titrate Duration Reversal Inhalational Rapid Rapid Controlled Easy

Oral Slow No Prolonged Hard Intravenous Rapid Rapid Prolonged Possible

Sedation Medications

Route/Modality Onset Titrate Duration Reversal Inhalational Rapid Rapid Controlled Easy

Oral Slow No Prolonged Hard Intravenous Rapid Rapid Prolonged Possible

Nitrous Oxide

N2O Properties

§  Sedation §  Analgesia

N2O Pharmacokinetics

§  Blood gas coefficent Pb/g-0.47 –  Low solubility in blood – Rapid uptake – Rapid elimination

§  0.004% biotransformation in GI tract – Excreted almost entirely unchanged

N2O Pharmacodynamics

§  MAC = 104 –  Low potency

•  At 104% Nitrous Oxide, 50% of patients experience general anaesthesisa

•  Between 20-50% Nitrous Oxide, patients experience conscious sedation

§  Cardiovascular Effects – Weak myocardial depressant – Mild sympathomimetic

• Minimal overall effect

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N2O Pharmacodynamics

§  Respiratory Effects – Weak respiratory depressant (êvolume) – Mild sympathomimetc (érate)

• May potentiate other agents • Healthy Patients: Minimal overall effect

– Decreased central hypercapnic response (C02) – Decreased peripheral hypoxemic response (O2)

•  Severe COPD patients can experience respiratory arrest

N2O Contraindications

§  Nasopharyngeal obstruction §  Severe COPD §  Closed Tissue Spaces §  Belomycin chemotherapy §  Claustrophobia §  Vitreoretinal surgery within 3 months

N2O Contraindications §  Nasopharyngeal obstruction

– Can you easily breathe through your nose? – Do you commonly get nasal congestion?

§  Severe COPD – Have you ever been told you should have home

oxygen? §  Closed Tissue Spaces

– Do you have middle ear disease?

N2O Contraindications §  Bleomycin chemotherapy

– Have you ever been treated with bleomycin? •  IV, IM, or SubQ antibiotic chemotherapy •  Lymphoma, testicular or squamous cell?

§  Claustrophobia – Do you get anxious in confined spaces?

§  Vitreoretinal surgery within 3 months – Have you had eye surgery in the past 3 months? –  If so, what type? – Perfluoropropane C3F8 or Sulfurhexafloride SF6

Is this a good choice?

§  Can you minimize leaks? (maximize dose) – Use a rubber dam? – Will patient exhale through their nose not mouth?

§  Is your patient likely to enjoy? – Finds alcohol relaxing? – Misinterpret symptoms as disturbing?

§  Procedural Considerations – Will the nasal hood be in the way?

Benzodiazepines

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BDZ Properties

§  Agonists of BDZ subunit GABA receptor

§  Anxiolysis §  Sedation §  Amnesia §  Muscle Relaxants §  Anticonvulsants

BDZ Pharmacokinetics

§  Absorption – Delayed – Average of 60 to 30 minutes – PO and SL routes have different effect

•  PO routes have a “first pass” through the liver before entering the systemic circulation (where they affect the brain)

•  Happens because venous blood from the intestine (where the drug is absorbed) enters the liver first

•  Dose reduction ~30% if given sublingual

BDZ Pharmacokinetics

§  Distribution – First to VRG (Brain) then Muscle and Fat

§  Biotransformation (Liver) – Chemical transformation of the drug by enzymes – Enzymatic degredation by Cytochromes P450;

CYP3A4 and CYP2D6 §  Elimination (Kidney)

– For a single dose, 4 half-lives are necessary before a drug is 90% eliminated.

BDZ Pharmacodynamics

§  Systemic effects negligible

§  Cardiovascular Effects – Minimal myocardial depression – High doses á HR â BP

§  Respiratory Effects – Minimal âRR â Volume as single agent – High doses â Hypoxic drive

Typical BDZ for Dentistry

§  Triazolam (Halcion) §  Diazepam (Valium) §  Lorazepam (Ativan) §  Alprazolam (Xanax) §  Temazepam (Restoril) §  Oxazepam (Oxpam)

Benzodiazapine Contraindications

§  Sleep Apnea §  Paradoxical Reactions

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Is this a good choice?

§  Can your patient swallow pills? – Or do they need to be crushed/ground?

§  How is that airway? – Respect for sleep apnea!

Dose Selection

Optimizing Dose

Amount of Drug è

Effe

ct o

n B

ody

è

Desired Effect

Side Effect N2O Dose Selection

N2O Ideal Sedation Symptoms Signs Relaxation Decreased muscle tone Light-headedness Transient increase in HR, BP Tingling of hands, feet, lips Normal respiration Warmth Periphreal vasodilation Light “floating” to heavy “sinking” feeling Mild euphoria

N2O Over-Sedation Symptoms Signs Laughing Restlessness Dreaming Sweating Tearing/crying Tearing/lacrimation Nausea Vomiting Dysphoria Persistent increase in HR, BP, RR

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Nitrous Oxide % Dose Selection

§  20% is a good starting point §  20-40% most patients enjoy distracting and

pleasant effects §  >50% most patients experience side effects,

especially nausea/vomiting §  70% may be required for some patients to feel

any effect, but this is rare – Check for leaks!

BDZ Dose Selection

BDZ Dose Considerations

§  Weight §  Age §  Systemic health §  Concurrent medications §  Chemical dependency §  Anxiety level

Triazolam Properties Time (hours)

Onset of Action 0.5-1

Peak Serum Concentration 1-2

Duration of Action ~2

Elimination Half Life 1.5-5.5

Best for Appointments <3

Available Oral Preparations 0.125 and 0.25 mg tablets

Dose Range 0.125-0.5 mg (0.004 mg/kg)

Diazepam (Valium) Properties Time (hours)


Peak Serum Concentration 0.5-2

Duration of Action 2-4

Elimination Half Life 20-80

Best for Appointments >2

Available Oral Preparations 2, 5, and 10 mg tablets

Dose Range 10-30 mg (0.065-0.3 mg/kg)

Lorazepam (Ativan) Properties Time (hours)

Onset of Action 1-2


Duration of Action Up to 8



Available Oral Preparations 0.5, 1, and 2 mg po and sl tablets

Dose Range 0.5-3 mg (0.02 mg/kg)

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Alprazolam (Xanax) Properties Time (hours)

Onset of Action 1-1.5


Duration of Action 4-6



Available Oral Preparations 0.25, 0.5, 1 and 2 mg tablets

Dose Range 0.25-0.5 mg

Temazepam (Restoril) Properties Time (hours)


Peak Serum Concentration 1.2-1.6


Elimination Half Life 3.5-18.4

Best for Appointments Data not available

Available Oral Preparations 15 and 30 mg capsules

Dose Range 7.5-30 mg

Oxazepam (Oxpam) Properties Time (hours)

Onset of Action ~1

Peak Serum Concentration ~2


Elimination Half Life ~8

Best for Appointments Data not available

Available Oral Preparations 10, 15, and 30 mg capsules

Dose Range 10-30 mg

Approximate Doses ASA I/II Patients

Drug Minimal Moderate Night Before Triazolam (Halcion) 0.125-0.25 mg 0.375-0.50 mg 0.125-0.25 mg

Diazepam (Valium) 10-15 mg 20-30 mg 5-10 mg

Lorazepam (Ativan)

0.5-1 mg 2-3 mg -

Alprazolam (Xanax) 0.25 mg 0.5 mg 0.25 mg

Temazepam (Restoril) 15 mg 20-30 mg -

Oxazepam (Oxpam) 10-15 mg 15-30 mg -

BDZ Dose Selection

STEP 1: What is my sedation goal? – Minimal sedation

STEP 2: Begin with a weight-based dose – This is your starting point

STEP 3: Consider dose modifiers – Age/health status? –  Liver enzymes? – Anxiety level? – Special reason to be cautious?

BDZ Dose Selection

§  Weight – Use “ideal” not actual body weight – Must dose to lean body mass to avoid overdose

Ideal body weight (BMI): http://www.halls.md/ideal-weight/body.htm (Or estimate)

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BDZ Dose Selection

Liver enzymes? §  Enzyme induction? = need more drug

– Smoking/alcohol abuse – Daily benzodiazepines?

§  Enzyme inhibition? = need less drug – CYP3A4 inhibitors: erythromycin, clarithromycin,

azole antifungals, cimetidine, grapefruit juice – Age, poor systemic health

BDZ Dose Selection

Anxiety level? §  Mild anxiety?

– Stick to weight dose §  Moderate anxiety?

– Modest increase in dose

Example: Triazolam

40 yo F 5’4” (64cm) 210 lbs (95kg) Healthy, Non-drinker, Smokes ½ pack/day Very anxious!

0.004 mg/kg x 90kg = 0.38 mg Pt is a heavy smoker and highly anxious, perhaps consider an increase in dose for a minimal sedation effect?

Closest dose = 0.5 mg

Example: Triazolam

40 yo F 5’4” (64cm) 210 lbs (90kg) Healthy, Non-drinker, Smokes ½ pack/day Very anxious!

Ideal body wt (based on BMI): 111-146 lbs For this example, assume 140 lbs; = 64 kg Actual wt: 0.004 mg/kg x 90 kg = 0.38 mg Ideal wt: 0.004 mg/kg x 64 kg = 0.25 mg Closest dose? = 0.375 mg NOT 0.5 mg

Triazolam Dose for Minimal Sedation

I recommend 3 Triazolam dosing strategies: 0.125 mg 0.250 mg 0.375 mg (0.5 mg)

Triazolam Dose for Minimal Sedation

Rationale for Triazolam dosing strategies: Dose Explanation 0.125 mg* Usually poor effect for healthy patients with moderate anxiety; Use

for elderly, fragile (medically compromised), small patients based on ideal body weight.

0.250 mg* Likely good effect; base on ideal body weight. May be unsatisfactory for highly anxious patients or those with enzyme induction (current benzodiazepine, alcohol, or smoking)

0.375 mg** May be minimal sedation when at previous appointment effect for 0.250 mg demonstrated to have limited or no effect.

(0.5 mg) Most likely moderate sedation; avoid this dose.

*RCDSO recommended minimal sedation doses **Possible moderate sedation – monitor effect closely to ensure minimal

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Continuum Depth of Sedation

§  It is not always possible to predict how a patient will respond

§  Individuals administering sedation need to be able to rescue patients who enter a state of deeper sedation than intended

Examples of Minimal Sedation

§  40% N2O:O2 §  0.25 mg triazolam §  0.125 mg triazolam + 30% N2O:O2 And….

patient answers you intelligibly when you ask a question. You may have to gently touch them, but they will respond rapidly and sensibly.

Objective 3

Establish policies and practices in their office which comply with RCDSO regulations.

General Categories of Regulations

§  Training and Education §  Provider and Facility Permits §  Facility Resources §  Patient Evaluation §  Documentation §  Emergency Preparedness

Training & Education

Assumptions of Regulators

Sedation Minimal Moderate Deep Modality •  N2O alone

•  1 drug •  1 drug + N2O

•  Multiple oral medications

•  IV

•  Ketamine •  Propofol

Monitoring Basic Increased Advanced

Training Basic Increased Advanced

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§  “Successful completion of a training program designed to produce competency in the specific modality of sedation utilized is mandatory.” (#1, p.2) – Document your continuing education – Include this course in your training


§  “Training program must be obtained from one or more of the following sources” (i, p.6) – Undergraduate or postgraduate program – Continuing education courses

• Teachers certified sedation/anesthesia • Permit candidates to utilize techniques**


§  “Followed by a recorded assessment of the competence of candidates.” (i, p.6)

• Course where you have taken a test**


Provider & Facility Permits

Do I need a provider permit for minimal sedation with.. §  Oral benzodiazepines?

– No. §  Nitrous Oxide and Oxygen Sedation?

– No.

Do I need an office inspection for minimal sedation with… §  Oral benzodiazepines?

– No. §  Nitrous Oxide and Oxygen Sedation?

– No.

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Facility Resources

§  “In order to avoid allegations of sexual impropriety, additional appropriate staff should be present in the treatment room at all times whenever sedation is used.” (#11 p.4) – Alter cognition – Dream-like state – Sexual phenomena

RCDSO Guidelines Section????

§  “1. Administration of Nitrous Oxide and Oxygen”

§ Gas delivery system – Scavenging – Separate reserve “E” cylinder of oxygen – Written record of annual maintenance/

servicing kept on file for review as required

RCDSO Standards of Practice Additional Standards

§  “All automated monitors must receive regular service and maintenance by qualified personnel according to their manufacturer’s specifications, or annually, whichever is more frequent.”

§  “A written record of this annual maintenance/servicing must be kept on file for review by the RCDSO as required.”

RCDSO Standards of Practice Sedation Equipment (p.9)

Mandatory Equipment

§  Standard Emergency Medications + – Reversal Agents (Flumazenil) – Ensure E-tank Oxygen (+Face Mask)

§  Blood Pressure Monitior – Manual stethescope and sphygomanometers of

appropriate sizes

§  Pulse Oximeter* – Audio alarm settings

*N/A nitrous alone, single oral agent alone

Pulse Oximetry

§  The pulse oximeter is an essential monitor for dentists who provide sedation

n  Introduced in the 1980’s n  Noninvasive, inexpensive, simple monitor

of respiratory function n  Detects hypoxemia (↓oxygen in blood)

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How it works (3) – Physiology (A)

§  Hemoglobin is the active oxygen-carrying part of the erythrocyte (red blood cell)

§  If all 4 Hb molecules bind with oxygen, there is 100% saturation

Physiology (B)

§  Pulse oximeters measure arterial oxygen saturation, (SaO2) which is the affinity for oxygen binding to hemoglobin and physiologically related to arterial oxygen tension (PaO2) according to the oxyhemoglobin (HbO2) dissociation curve

Physiology (B)

§  If the oxygen unloads from the Hb molecule to the tissues and is not replaced, the hemoglobin saturation falls

Limitations (1)

§  Measures oxygen saturation, NOT content, therefore cannot provide actual measure of tissue oxygenation

Limitations (2)

§  Signal processing §  Ambient light §  Low perfusion §  Motion artifact

§  IV Substances §  Dyshemoglobins §  Intravenous dyes

§  Pigmentation §  Skin §  Nail polish

§  “2. Oral Administration of a Single Sedative Drug” Additional Responsibilities (p. 8) – Emergency Equipment

• Full face masks of appropriate size and connectors

• Fumazenil

RCDSO Standards of Practice

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23

Essential Emergency Drugs

DA Haas, Dent Clin N America, 2002

N2O Reversal: 100% Oxygen

EASY!

BDZ Reversal: Flumazenil (Anexate)

§  Antagonizes effect of benzodiazepines on GABA receptor in the CNS

§  Contraindicated in patients given benzodiazepine for control of epilepsy

§  0.1 mg/mL ONLY IV 0.1-0.2 mg increments §  Onset 1-2 min, peak 6-10 min, duration 45

min (less than duration of benzodiazepine) therefore caution to monitor and re-dose

§  Have the drug in your kit, call EMS, and let the paramedics deliver it for you.

Patient Evaluation

§  “Dentists must take into account the maximum dose of local anaesthetic that may be safely administered, especially for children, the elderly and the medically compromised.” (p.4)

RCDSO Guidelines Professional Responsibilities

§  “Whenever sedation is used, the calculated maximum dose of local anaesthesia may need to be further adjusted to provide a greater margin of safety” (p.4) – Implies you calculate the maximum dosage

of LA for each patients – Do you?!?!

RCDSO Guidelines Professional Reponsibilities

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24

Calculating Max LA Dose

§  Patient-specific §  Based on patient weight §  # of cartridges simple way to keep track

3 Steps Max LA Dose

Step 1. How many milligrams of drug are in one cartridge? –  Need to know

•  concentration of drug (%) •  volume of cartridge you use (ml)

Step 2. What is the maximum dose for this patient? –  Need to know

•  weight of patient (kg) •  maximum recommended dosage of drug (mg/kg)

Step 3. How many cartridges can I give? –  Max dose (mg)/Amount drug (mg) per cartridge = # cartridges

Step 1: How many mg of LA in 1 Cartridge? §  What percent concentration is your solution?

–  i.e. Lidocaine 2%

§  Percent solutions represent grams per 100 ml –  i.e. 2% lidocaine = 20 mg/ml

§  1 North American cartridge = 1.8 ml –  20 mg/ml x 1.8 ml = 36 mg of lidocaine

Step 2: Maximum dose for your patient (mg)

Maximum Recommended Dose mg/kg (MAX)

Local Anaesthetic

Adult

Articaine 4% 7 mg/kg (500 mg)

Lidocaine 2% 7 mg/kg (500 mg)

Mepivicaine 2% (with

vasoconstrictor)

6.6 mg/kg (400 mg)

Mepivicaine 3% (plain)

7 mg/kg (400 mg)

Prilocaine 4% 8 mg/kg (500 mg)

DA Haas, J Can Dent Assoc, Oct 2002

Step 2: Maximum dose for your patient (mg)

Pt Wt MRD Max Dose Pt Articaine

Adult 90 kg 7 mg/kg 630 mg 500 mg

Lidocaine Adult 90 kg 7 mg/kg 630 mg

500 mg

Step 3: Maximum dose for your patient (cartridge)

§  Lidocaine 2% – 500 mg is the MRD for a 90 kg patient – 2% lidocaine has 36 mg in 1 cartridge

– 500/36 = 13

– Maximum number of cartridges of 2% lidocaine is 13.

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§  “All patients must be specifically assessed for fitness for discharge” (iv, p.6)

RCDSO Standards of Practice Discharge Fit for Discharge?

§  Alert §  Oriented §  Ambulatory §  Recovering §  Pain/Bleeding managed §  Returned to the same condition as upon arrival

§  “1. Administration of Nitrous Oxide and Oxygen” Additional Standards (p.8)

•  “Only fully recovered patients can be considered for discharge unaccompanied.

•  If discharge occurs with any residual symptoms, the patient must be accompanied by a responsible adult.”


§  “1. Administration of Nitrous Oxide and Oxygen” Additional Standards (p.7)

§  “Recovery status post-operatively must be specifically assessed and recorded by the dentist, who must remain in the facility until that patient is fit for discharge.”


§  “2. Oral Administration of a Single Sedative Drug” Additional Responsibilities (p. 8) – Discharged when

• Oriented (person, place, time) • Ambulatory • Vital signs stable (baseline) • Signs of increasing alertness


§  “2. Oral Administration of a Single Sedative Drug” Additional Responsibilities (p. 8) – Discharged to

• The care of a responsible adult – Discharged with

• Postoperative W/V instructions


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Documentation

Informed Consent

§  Separate written consent §  Discussion about the medication and its

expected effects – Relaxed, not asleep – Fuzzy memories (BDZ)

§  Written Pre-operative and Post-operative instructions explained

§  “1. Administration of Nitrous Oxide and Oxygen” (p.7) Can be administered by – Trained dentist – Trained registered nurse (RN, RPN)/

respiratory therapist (RT) • Dentist is present/immediately available • Patient received N2O sedation before • Dosage levels previously determined

and recorded by the dentist in pt chart


§  “1. Administration of Nitrous Oxide and Oxygen” (p.7) – Direct and continuous monitoring by DDS,

RN, or RT (Note: cannot be monitored by a hygenist – DDS, RN or RT must always be in the room)

– Never left unattended by DDS, RN or RT


§  “1. Administration of Nitrous Oxide and Oxygen” Additional Standards (p.7) – “….continuous clinical observation for level

of consciousness and assessment of vital signs which may include heart rate, blood pressure, and respiration preoperatively, intraoperatively, and postoperatively, as necessary”


§  “2. Oral Administration of a Single Sedative Drug” Additional Responsibilities (p. 8) – Dose administered in-office

• Except 1: facilitate sleep the night before • Except 2: sedation permits office arrival

– Accompanied to* and from the office – Monitored by clinical observation of the

•  level of consciousness • assessment of vital signs (HR, BP, RR)


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§  “3. Oral Administration of a Single Sedative Drug with Nitrous Oxide and Oxygen Additional Responsibilities (p. 9) –  Must be specifically trained, evaluated, and received

documentation of competency –  Slow titration of nitrous oxide to avoid exceeding

minimal sedation –  Continuous pulse oximeter monitoring –  Audible audio output and alarms at all times

RCDSO Standards of Practice Written Record

§  Updated MH §  Pre-operative vital signs §  Confirm NPO §  Confirm Ride (if BDZ) §  Drug, dose, duration of sedation §  Post-operative vital signs §  Discharge criteria met §  Discharged to responsible adult (if BDZ)

Sample N2O Patient Record

§  Example: HH: See Sedation Consult form. Reviewed health history with XX; no changes. No solids since XX AM/PM, no liquids since XX AM/PM. Pre-op BP XXX/XX, HR XX, RR XX. Sedation start XX AM/PM. Nitrous oxide: X L Nitrous at XX % for XX minutes, followed by 100% oxygen for 5 minutes. Patient conscious and comfortable throughout. Sedation end XX AM/PM. Post-op BP XXX/XX, HR XX, RR XX. Post op instructions written and verbal given to XX. Discharged at XX AM/PM: Vital signs stable, awake, alert, ambulatory. !

Sample Oral Sedation Patient Record

§  Example: HH: See Sedation Consult form. Reviewed health history with XX; no changes. NPO since XX AM/PM, ride confirmed. Pre-op BP XXX/XX, HR XX, RR XX. Sedation start XX AM/PM. 0.25 mg triazolam po 45 min prior to procedure with good effect for minimal sedation (relaxed, comfortable). Pt immediately responsive to verbal commands throughout. Sedation end XX AM/PM. Post-op BP XXX/XX, HR XX, RR XX. Post op instructions written and verbal given to XX. Discharged at XX AM/PM to father (George) taxi. VSS: awake, alert, ambulatory. !

Sample Oral Sedation Patient Record

§  Example: HH: See Sedation Consult form. Reviewed health history with XX; no changes. NPO since XX AM/PM, ride confirmed. Pre-op BP XXX/XX, HR XX, RR XX. Sedation start XX AM/PM. 0.375 mg triazolam po 45 min prior to procedure with adequate effect for minimal sedation (anxiolyis, no hypnosis). Pt responded normally with voice and light touch throughout. Sedation end XX AM/PM. Post-op BP XXX/XX, HR XX, RR XX. Post op instructions written and verbal given to XX. Discharge at XX AM/PM to adult (sister) private car. VSS: awake, alert, ambulatory. !

Emergency Preparedness

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§  “All dentists and office staff must be prepared to recognize and treat adverse responses using appropriate emergency equipment and appropriate and current drugs when necessary.” (p.3)


§  “Should the administration of any drug produce depression beyond that of conscious sedation, the dental procedure should be halted. Appropriate support procedures must be administered until the level of depression is no longer beyond that of conscious sedation, or until additional emergency assistance is effected.” (iii, p.6)

Sedation Emergency

§  (p.3) Written protocols for emergency procedures – Review with staff regularly


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29

§  (p.3) BLS (CPR Level HCP) – Current certification strongly recommended


Why Recertify?

§  Evidence suggests the retention of BLS and ACLS knowledge and skills is poor – After a 1 day course, 1 year later MDs and

RNs show significant deterioration, with performance returning to pre-training levels Gass & Curry Can Med Assoc J 1983

– After BLS course, 6 months later no MD or RN performed all management steps correctly Kay & Mancini Crit Care Med 1986

Why Recertify?

§  Dental students trained in CPR not capable of managing a cardiac arrest 3 months later Laurent et al J Dent Educ 2009 –  >50% judge themselves competent in CPR –  50% failure to check for circulation –  50% failure to deliver adequate compressions

§  Dentists trained in CPR lack knowledge and confidence Gonzaga et al Brazil Dent J 2003 –  59% judge themselves competent; but only 46% can

correctly identify BLS concepts

BLS: Circulation-Breathing-Airway

§ C: Circulation – Heart sends oxygen to brain

§ B: Breathing – Lungs send oxygen to blood for heart

§ A : Airway – Patent airway provides oxygen to lungs

Sedation can compromise all of these systems.

What matters is rescue

§  “It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause” –  AHA Guidelines 2010

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Signs of Airway Obstruction

§  Snoring §  Exaggerated Respiratory Effort

–  Use of accessory muscles

§  (Wheezing) §  (Stridor) §  Absence of breath sounds

Head-Tilt Chin-Lift

Head-Tilt Chin-Lift UPPER AIRWAY ANATOMY

§  Upper airway obstructed by tongue in oropharynx

§  Head-tilt chin lift opens upper airway

Head tilt–chin lift.



Jaw thrust without head tilt.



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§  Oropharyngeal airway may help to maintain patency

UPPER AIRWAY Oral Airway Insertion

Face shield.



Mouth-to-mask, cephalic technique.



One-rescuer use of the bag mask.



Two-rescuer use of the bag mask.



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Putting it all together

Sedation Ready

§  “What’s my action list to be able to do minimal sedation in my office tomorrow?”

Patient Evaluation

q  Current, updated medical history q  Indication for sedation q  Core Physical Exam (Vital Signs) q  Core Medical History

q  Functional Inquiry (RESP, CVS) q  Airway assessment

q  Assign ASA Status q  Max LA Dose Calculation

Patient Preparation

q  NPO (2 hrs nitrous, 4 hrs BDZ) q  Ride (BDZ) q  Written Post-operative instructions

Provider Preparation

q  Appropriate Training q  Current BLS (Healthcare provider) q  Sedation Assistant

– Patient cannot be left unattended – You cannot be alone with the patient!

q  Emergency Protocols

Facility Preparation

q  Functioning equipment, maintained q  Basic Medical Emergency Drugs q  E-tank Oxygen (separate supply) q  Ambubag (full face mask, with connectors) q  Manual stethescope and sphygomanometers q  Flumazenil (if using benzodiazepines) My additional Recommendations: q  Pulse oximeter q  Selection of oral airways

101 Elm Street Toronto ON M5G 1G6

Nitrous Oxide and Oxygen Sedation is a safe and effective method to limit anxiety and create relaxation. Follow these instructions carefully. They are for your safety.

BEFORE THE APPOINTMENT

1. DO NOT EAT OR DRINK: NO FOOD OR DRINK within 2 hours of your dental appointment. The last meal before your appointment should be a light, low-‐fat meal (avoid dairy, no fried fatty food). The last drink before your appointment should be water, clear juice (apple juice), or black coffee (avoid dairy or dairy substitutes) as these are easy to digest.

Last Meal -‐ Light, Low-‐Fat 2 HRs 1 Appointment LAST SOLID FOOD LAST DAIRY DRINK

NO FOOD NO DRINK

3. MEDICATIONS: Take all regular medications at their usual time, with sips of water only. In rare instances, you may be asked not to take a certain medication. If you are not sure, check with your student.

4. WHAT TO WEAR: Loose, comfortable clothing is best. Do not wear nail polish.

5. ILLNESS: If you become sick or ill at anytime leading up to your appointment, call your student. Report any health changes such as new medical diagnosis, new illness, cough/fever, cold or flu. Bring an updated medication list to your appointment and be prepared to answer questions about your health. AFTER THE APPOINTMENT

1. ACTIVITIES: Following the administration of 100% Oxygen for five minutes, you should be fully recovered from the sedation and can resume your normal activities.

2. FOOD AND DRINK: Depending on your dental treatment, you may need to modify your diet. It is important to resume fluid intake after your appointment to prevent dehydration. Make sure you resume drinking following your sedation. Start with small sips of water and drink more as able.

Student Name: ______________________________________________________________

Daytime Phone: 416-‐979-‐4900 Ext. ___________ OR ________________________________

After hours or in an emergency, contact your nearest hospital emergency department.

PATIENT INSTRUCTIONS Nitrous Oxide and Oxygen Conscious (Minimal) Sedation

101 Elm Street Toronto ON M5G 1G6

Oral Conscious Sedation is a safe and effective method to limit anxiety and create relaxation.

Follow these instructions carefully. They are for your safety. BEFORE THE APPOINTMENT

1. MAKE PLANS FOR GETTING HOME: You will not be able to drive after your appointment. Under no circumstances may you use public transportation. You may only go home in 1) a private vehicle or 2) a taxi. You must have a responsible adult to escort you home. You must go directly to a place where you can rest.

You escort should arrive to _____________________________________ at _______________ to pick you up.

2. DO NOT EAT OR DRINK: For best absorption of the sedative medication. do not eat within 4 hours of your dental appointment. The last meal before your appointment should be a light, low-‐fat meal (avoid dairy, no fried fatty food). WATER, CLEAR JUICE, and BLACK COFFEE (NO DAIRY or dairy substitutes) are easy to digest and allowed up to 2 hours before your appointment. NO FOOD OR DRINK within 2 hours of your appointment.

Last Meal – Light, Low-‐Fat 4 HRs 3 2 HRs 1 Appointment LAST SOLID FOOD LAST DAIRY DRINK

NO FOOD Water, clear juice, black coffee ONLY

NO FOOD NO DRINK

3. MEDICATIONS: Take all regular medications at their usual time, with sips of water only. In rare instances, you may be asked not to take a certain medication. If you are not sure, check with your student.

4. WHAT TO WEAR: Loose, comfortable clothing is best. Do not wear nail polish.

5. ILLNESS: If you become sick or ill at anytime leading up to your appointment, call your student. Report any health changes such as new medical diagnosis, new illness, cough/fever, cold or flu. Bring an updated medication list to your appointment and be prepared to answer questions about your health. AFTER THE APPOINTMENT

1. ACTIVITIES: After your appointment, your motor coordination and cognitive function will be impaired. You may not operate a motor vehicle or machinery, consume alcohol, engage in decision-‐making, business transactions, or online social media for 18 hours, or longer if dizziness/drowsiness persists. Rest is best.

2. FOOD AND DRINK: Depending on your dental treatment, you may need to modify your diet. It is important to resume fluid intake after your appointment to prevent dehydration. Make sure you resume drinking following your sedation. Start with small sips of water and drink more as able.

3. SEEK ADVICE: If you have difficulty breathing, nausea or vomiting that persists beyond 2 hours, a sensation of dizziness or drowsiness 6-‐8 hours after your appointment, or any other matter that causes you concern. Student Name: ____________________________________________________________________________

Daytime Phone: 416-‐979-‐4900 Ext. ___________ OR ______________________________________________ After hours or in an emergency, please contact your nearest hospital emergency department.

PATIENT INSTRUCTIONS Oral Conscious (Minimal) Sedation

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