1
Q
What can sedation be used to do
A
- Manage dental treatment phobia
- Suppress the gag reflex
- Reduce anxiety and discomfort for patients undertaking difficult procedures
- Treat patients with anxiety induced medical conditions
- To treat patient with mild to moderate learning difficulties
2
Q
What are the advantages of intravenous sedation
A
- Much safer than general anaesthetic when performed correctly
- Is an outpatient procedure
- Patients generally feel a dramatic reduction anxiety
- Generally makes patient more compliant with treatment
- Can make treatment easier due to reduced need to manage anxiety
3
Q
What is a unique advantage of IV sedation over inhalation sedation
A
Patients forget most unpleasant experiences in IV sedation
4
Q
What are the disadvantages of intra venous sedation
A
- Patients do not always respond predictability
- Retrograde amnesia means patients anxiety isn’t cured
- Not guaranteed that treatment will be possible
- At the second visit patient may think they were asleep in the last visit
- Increased risk of medical complications
- Oral access may be compromised
5
Q
What are the stages of intravenous sedation
A
- Pre assessment (separate visit)
- Pre op checks
- Pre op preparation for you and patient
- IV access
- Sedation
- Clinical procedure
- Recovery
6
Q
What do we need to be monitoring during the clinical procedure under sedation
A
- BP
- Heart rate
- O2 saturation
7
Q
What do the pre op checks include
A
Checking:
1. Equipment
2. Drugs in date, right amount, in correct place
3. staff ready
4. Treatment plan
5. Medical history changes
6. Escort present and appropriate
7. Consent appropriate an sup to date
8. Base line observations
8
Q
What are the baseline observations we record during pre op checks
A
- General appearance
- Blood pressure
- Pulse
- Respiratory rate and oxygen saturation
9
Q
What pre op preparation do you need to do
A
- Do you have all the equipment required to complete the procedure
- Are you competent enough to do the procedure
- Are the relevant investigation available
- Have you planned for any complications
10
Q
Can a patient consent once they have had the sedation drug
A
no
11
Q
What pre op prep do we need from the patient
A
- Pre op checks are within acceptable limits
- Patients has fasted as appropriate
- Topical skin anaesthesia if required
- Does pt need a toilet break
- Is pt aware of what is planned for the session
12
Q
If a pt is diabetic what else might we check pre op
A
Pre op blood glucose
13
Q
What drugs do we use for sedation
A
Midazolam 5mg in 5ml
14
Q
In regards to the drugs what do we need to prepare post op
A
- PPE
- Label syringes
- Check drug type, concentration and expiry date
- Draw up saline and midazolam into appropriately labelled syringes
15
Q
At the LDI what is our preferred concentration of midazolam
A
1mg per ml
16
Q
Where can we cannulate for IV sedation
A
- Antecubital fossa
- Dorsum of the hand
17
Q
Name the 2 veins we tend to use for IV sedation
A
- Basilic vein
- Cephalic vein
18
Q
Talk through the pathway of the basilica vein
A
- Ascends along the medial surface of the forearm near the elbow
- Changes to a position in front of the medial epicondyle where is is joined by the median cubital vein
- Runs along the medial margin of the biceps muscle to the middle of the upper arm
- Pierces the deep fascia to run alongside the brachial artery becoming the axillary artery
19
Q
Talk through the pathway of the cephalic vein
A
- Ascends on the front of the lateral side of the forearm to the front of the elbow
- Ascends along the lateral surface of the bicep muscle to the lower border of the pectorals major muscle
- Pierces the clavipectoral fascia and passes beneath the clavicle
- Terminates in the axillary vein
20
Q
What does the cephalic vein communicate with
A
The basilica vein through the medial cubital vein
21
Q
What are found at the termination of the cephalic vein
A
Valves
22
Q
How can valves cause a problem during IV sedation
A
The sharp angles and calves may hinder her passage of a catheter along the cephalic system
23
Q
What are the advantages of using the antecubital fossa
A
- Less vulnerable to vasoconstriction in cold weather
- Usually bigger and well tethered veins which are easier to cannulate
- May be less painful than dorsum of the hand
24
Q
What are the disadvantages of using the antecubital fossa
A
- Vein may be less visible particularly with increased BMI
- Brachial artery and median nerve are medial to bicep tendons and we do not want to cannulate this
- May be less obvious if the cannula is incorrectly placed
25
What do we need to place and where before cannulating on the dorsum of the hand
Need to place a tourniquet around the lower forearm above the wrist
26
What are the advantages of using the dorsum of the hand fro IV sedation
1. Veins tend to be more visible
2. Not likely to damage important vessels or nerves
3. May be more obvious is cannula is incorrectly placed
27
What are the disadvantages of using the dorsum of the hand fro IV sedation
1. Vulnerabel to vasoconstriction in cold weather
2. Usually smaller and more mobile veins which are harder to cannulate
3. Tends to be more painful
28
What can we do if we want to cannulate the dorsum of the hand but it was cold outside
We can place the patients hands in hot water to help ease the vasoconstriction
29
What equipment do we need for the provision of dental IV sedation
1. Tourniquet
2. Midazolam 5mg per 5ml ampule
3. Filter needle
4. Syringe
5. safe snap ampule to open midazolam
6. sodium chloride for saline flush
7. Timer
8. Sterile gloves
9. Cannula
10. Skin prep
11. Dressing
12. Reversing agent
30
What do we want to do to prepare for intravenous access
1. Take your time
2. Look and feel for a good vein
3. Occlude the venous return
4. Gently tap and rub over the vein
31
How can we occlude the venous return
1. Tourniquet
2. Nurses hand
3. Pressure cuff
32
What can we do if we have problems finding a vein
1. Warn the hand in water
2. Consider inhalation sedation to help vasodilate the veins
33
How do we check the cannula is correctly placed
1. There should be no haemoatoma around the insertion site
2. Flush the cannula with saline via the portal (at least 2ml)
3. If there is swelling pain or resistance cannula may be incorrectly placed
34
What 3 signs suggest cannula may be incorrectly placed
1. Swelling
2. Pain
3. Resistance
35
Talk through the steps of sedating the patietn following cannulation
1. Check observations before commencement
2. Make sure syringe is firmly attached to the cannula
3. Start the timer
4. Give 1mg of midazolam iv slowly and wait to observe the effect
5. Titrate the dose against the clinical effect
6. Give additional 1mg increment as required
7. Be patient
36
How long do we wait between each 1mg increment
Wait at least a minute to let the drug travel to the brain
37
Which patients may taker longer to exhibit an effect to midazolam
1. Patients with high alcohol tolerance
2. Patients who have previously taken midazolam
38
What are we looking for when assessing clinical effect
1. Relaxed demeanour
2. Slurred speech
3. Delayed response to questions
4. Comfortable about starting treatment
5. May complain of itchy nose and leg over
39
What signs may we look for when assessing the clinical effect of midazolam
1. EVE's sign
2. Verrill's sign
40
What is EVE's sign
Asking the patietn to touch their nose which they may not be able to locate
41
What is Verrill's sign
Pulpil being partially cloaked
42
What must we be aware of when carrying out treatment under sedation
Airway is partially compromised
Gag and cough reflexes can be suppressed
43
How many people do we need to operate safely under sedation
3
you
your nurse to assist
another to monitor the patient
44
How do we manage the sedated patient during treatment
1. positive dialogue
2. Be authoritative
3. Speak clearly and firmly
4. Tell the patient what you are going to do and ask for permission
45
Do we give a reversing drug to speed a patients recovery from midazolam
no not routinely
46
How do we go about recovery post sedation
1. Leave the cannula in place until ready for discharge
2. Make sure observations are normal fro patients
3. Discharge not until at least 1 hour after last increment of midazolam
4. Ensure patient is able to stand and walk unaided
5. Give. post op verbal and written instruction to escort
5th yr- AMS
flashcards
Decks in class (11)
# Cards
-
Patient selection for IV sedation22
-
Pre sedation assessment24
-
Sedation technique46
-
Equipment for the provision of dental IV sedation13
-
Clinical monitoring in sedation33
-
Inhalation sedation 135
-
inhalation sedation 234
-
Pharmacology0
-
Complications and respiratory depression58
-
Medication considerations and drug interactions in sedation103
-
General anaesthesia in Dentistry56
