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 appropriate to 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 Interest Commercial Support

Multiple Guidelines
Hospital Guidelines College of Dentistry Guidelines ASA Guidelines for Sedation by the

ADA Guidelines for the Use of AAOMS & AAPD Guidelines

Conscious Sedation, Deep Sedation and General Anesthesia by Dentists

Non-Anesthesiologist

ADA Guidelines
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 of university-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 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, you must complete 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; 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 York State Board for Dentistry as meeting the 18-hour university-based didactic training requirement for the NY enteral sedation permit.

NY Regulations
Conscious sedation means a minimally 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 and that is produced by a pharmacologic or nonpharmacologic method or a combination thereof. Patients whose only response is reflex withdrawal from repeated painful stimuli shall not be considered to be in a 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

Implications?
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.

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. Minimize discomfort and pain. Minimize negative psychological responses by providing adequate sedation, analgesia and amnesia. Decrease agitation and improve cooperation during a procedure. 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 infusion designed to maintain a steady state (i.e. a constant plasma concentration) has been stopped. The "context" is the duration of infusion.

Half-Life ?

Half-Life ?

Half-Life ?

Half-Life ?

Half-Life ?

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 increased 90%. Doses should be titrated. CHF: Following oral administration (7.5mg), t increased 43%

Demerol (Meperidine)
Meperidine protein binding is high Opioid Analgesic t is 3to4 h 10 to 45 min The times to peak effect are 3 to 50min Children (IM/Subcutaneous), 60 to 90 min (oral), and 5 to

7min (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

Phergan

Promethazine is a phenothiazine derivative Promethazine is an H1 receptor blocking agent. In addition to its antihistaminic action, it provides clinically useful sedative and antiemetic effects Promethazine is well absorbed from the gastrointestinal tract. Clinical effects are apparent within 20 minutes after oral administration and generally last four to six hours, although they may persist as long as 12 hours Promethazine is metabolized by the liver to a variety of compounds

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

 Short (e.g. ext single tooth)

Regimens

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 on

our 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 max
1000mg

+ 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.

NPO

NPO
Delayed 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 not expected to require operative intervention.

NPO
Conclusion
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 clear liquid 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

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 adverse

events

Risk Management Committee By 2000: 50 States regulated GA, CS

and 3 oral sedation

 43 Cases HR - 68 Can t detect moderate changes RR - 77 Result - too little, too late BP - 77 Oxygenation - 92 H Rhythm - 96

Is it necessary? (percentage not monitored)

Monitoring/Documenta tion
Enteral/Enteral-Inhalation

Patient Evaluation Pre-Operative Preparation Personnel Equipment

Routine PreOp Monitoring BP

HR Hrhythm RR Temp Height Weight

Monitoring
Direct Clinical Observation of the
Patient must occur

Oxygenation Ventilation Circulation

Oxygenation
Color of Mucosa, Skin, Blood Pulse Oximetry

Pulse Oximetry
70% of episodes SpO2 <81 not
detected visually by anesthesiologist

SpO2 varies with age, pulmonarycardiovascular 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 PaO
2

Oxyhemoglobin Dissociation Curve

Relates SpO to PaO Normal PaO Healthy Child 90 - 100 mmHg O Equals SpO > 98% Based on Room Air O = 21% FiO Supplemental O Higher PaO
2 2 2 2

99

95

90

90

50

28

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 Low Pulse Amplitude Errors

Movement

Anemia less than 10%

Dyshemoglobins

Carboxyhemoglobin Methemoglobin Sickle Cell Anemia

Dyes, Electrocautery, Fingernail Polish, Skin Pigment

Respiration / Ventilation

Very Important Determine Respiratory Rate

Observe Rise and Fall of chest wall

Observe Color Observe Movement of Reservoir Bag Precordial Stethoscope EKG - impedance

Ventilation Chest Excursions

Pre-Tracheal/Cordial Stethoscope Continuous, Immediate Evaluation of

Ventilation

Difficult with Draped Patient

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 Monitoring

Infrared Endtidal Levels Wave Form

Respiratory Rate
Neonate 1yr 5yr
40 25 20

12yr 21yr

16 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 continuous monitoring required

Terms continual - repeated regularly and frequently in a steady succession continuous - prolonged without any interruption

Pulse
Newborn 1yr 5yr 10yr
120 120

100
90

Blood Pressure
200/115 = ASA IV After administration of drug or change
in rate of administration

Automatic / Manual BP - w/wo

stethascope

! IV / SpO2

Common BP
Newborn Infant Child Teenager
80/45 100/60

110/60
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

Circulation

Color

Mucosa, Skin, Blood

Pulse Oximetry

Ventilation
Chest Excursions Auscultate Breath Sounds Capnography

Blood Pressure
Heart Rate Electrocardiography

Temperature

Recovery & Discharge

Oxygen and suction equipment must be
immediately available in the recovery area and/or operatory.

Continual monitoring of oxygenation, ventilation

and circulation when the anesthetic is no longer being administered; patient must have continuous supervision until oxygenation, ventilation and circulation are stable and the patient is appropriately responsive for discharge from the facility.

Recovery/Discharge contd.
Must determine and document that oxygenation,
Must provide explanation and documentation of The dentist must determine that the patient has
postoperative instructions to the patient and/or a responsible adult at the time of discharge. met discharge criteria prior to leaving the office.
ventilation and circulation are stable prior to discharge.

Temperature
Required When Triggering Agents for
Malignant Hyperthermia Planned

Slightly Elevated Temperature Not

Uncommon Prior to Procedure Or May Signal Impending Illness

Elevated Temperature Increases

Cardiac 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 the procedure; ASA physical classification

Medications used, and dosages

Any complications and who was notified of any complications (family, attending MD)

Sedation Record
Time Oriented Record

Preferably Contains All Information Relative to Sedation

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 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

Moves all extremities voluntarily/ on command

Breaths deeply and coughs freely.

BP + 20 mm of preanesthetic level

Fully awake

Pink

Moves 2 extremities

Dyspneic, BP + 20-50 mm shallow or of preanesthetic limited breathing level

Arousable on calling

Pale & Dusky

Unable to move extremities

Apneic

BP + 50 mm of preanestheic level

Not responding

Cyanotic

Modified Aldrete Scoring

Vital Signs (BP and Pulse) Activity Nausea and Vomiting Pain Surgical Bleeding

Within 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

20-40% of preoperative baseline

Requires assistance

Not acceptable Moderate: treat to the patient; with IM not controlled medications with PO medications

Moderate: up to 2 dressing changes

>40% of preoperative baseline

Unable to ambulate

Continues: repeated treatment

Severe: more than 3 dressing changes

Escort/Discharge

Stable Vital Signs/Awake/Ambulatory Escort Must Be Present On Discharge

Escort Must Be Responsible Adult

Post-Op Instructions To Escort & Preferably Written 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 Drugs

Oxygen Vasodilator Bronchodilator Antihypoglycemic Aspirin