Shaleny Doraysamy P07 204

A controlled, pharmacologically induced, minimally depressed level of consciousness that retains the patients ability to maintain patent airway independently and continuously and respond appropriately to physical stimulation and verbal command.

DEEP SEDATION

A controlled state of depressed consciousness, accompanied by partial loss of protective reflexes, including inability to respond purposefully to a verbal command

GENERAL ANESTHESIA

A controlled state of unconsciousness, accompanied by partial or complete loss of protective reflexes, including inability to maintain an airway independently and respond purposefully to physical stimulation and verbal command

AMBULATORY, OUTPATIENT OR DAY CARE ANESTHESIA

Delivery of anesthetic care in which patients are discharged home on the day of treatment.

  

To guard the patients safety and welfare To minimize physical discomfort and pain To control anxiety, minimize psychological trauma, and maximize the potential for amnesia To control behavior and/or movement so as to allow the safe completion of the procedure To return the patient to a state in which safe discharge from medical supervision

Very young uncooperative children who require multiple fillings may be unable to sit for treatment.

All of the child's treatment can usually be completed in one visit. Allows minimal discomfort and to return in six months as a good dental patient.

Fear, Anxiety and Phobia Low Pain Threshold & Inability to Get Numb

There are many patients who have a low pain threshold and others who are unable to get numb with local anesthesia injections. These patients are good candidates for intravenous moderate (conscious) sedation. Patients who require a great amount of dental care can have that care provided in a shorter amount of time. For example, if a patient has several teeth that require root canal treatment, all these teeth can usually be treated in one visit. This enables the patient to combine multiple visits into one. Autistic, ADHD Patients with neurological diagnosis have uncontrolled movements which make dental treatment without sedation or general anesthesia impossible. Patients with some cardiac problems are better treated with sedation, which can reduce cardiac stress during treatment. Due to some cardiac problems patients may require intravenous antibiotics

Extensive Treatment

Special Needs Patients (Physically and Mentally Challenged)

Medically Compromised

Chronic obstructive pulmonary disorder (COPD), myasthenia, epilepsy, obesity, bleeding disorders Unaccompanied patients, prolonged surgical procedures Allergy to any medications Children below the age of 1 year

SELECTION CRITERIA SHOULD BE DONE BASED ON

Oral Inhalation Intramuscular Intravenous Sublingual Rectal Intranasal Submucosal

Indications and benefits

Can be used for preoperative sedation Used for all levels of anxiety Better acceptability and ease of administration Lesser incidence of ARD

Limitation and risks

Delayed onset Some drugs may have high susceptibility to enzyme metabolism Patients compliance

Drugs commonly used

Chloral Hydrate Hydroxyzine Promethazine Diazepam Meperidine Chlorpromazine Triazolam

Techni

Administered hour rior to treatment, as onset of drug action varies from 3 to 6 minutes. eart rate, lood ressure, consciousness and res irator rate should e monitored throughout the rocedure. Apprehensive patients are placed on apoose oard, ith secured hands, legs and midbody. On discharging patient, full oral and ritten instructions should be given to the parents.

Indications and benefits

All levels of anxiety Rapid onset, with brief and comfortable procedure Early recovery Duration of action can be easily controlled

Limitations and risks

May not be completely sedated

Vomiting Claustrophobic due to mouth mask Rarely, dizziness

Drugs commonly used

Nitrous oxide

Desflurane Sevoflurane

State of sedation with varying degree of analgesia induced by inhalation of mixture of nitrous oxide and oxygen, retaining adequate laryngeal reflex Always administered with oxygen to safeguard patients oxygen supply Procedure :

Started by 100% oxygen administered for 2 to minutes.

Nitrous oxide is then administered with increasing concentration till a suitable sedation state is achieved ( 0-50%) Upon completion of treatment, 100% oxygen is administered for 5 minutes Dosage - A 1:1 mixture of oxygen and nitrous oxide

PLANE I : Moderate Sedation and Analgesia

Achieved with concentrations of 5-25 % of Nitrous Oxide Explain to patient the symptoms that may be felt

Eg. Floating, light feeling

Patient may sense dizziness, tingling sensation in fingers, toes, cheek, tongue Relaxation and reduced fear and anxiety Hearing, vision are impaired but pupils are normal Relaxed perioral musculatures

PLANE II : Dissociation Sedation and Analgesia

Concentrations of 25-45 % May or may not experience symptoms Psychological symptoms eg. Euphoric, or dissociation Reduction in blink rate Patient has pleasant dreams Patient is conscious and responds to questions

PLANE III : Total Anesthesia (Analgesia)

Concentrations of 45-65%

Complete analgesia Marked amnesia develops Zone between analgesia and light anesthesia

Subdivided into three planes :

Lightest Plane Kaleidoscopic images and thoughts Somnolent State Contact is maintained, where patients respond to signs eg. Open mouth sign Deepest Plane Patient only carries out simplest commands after repetitions

PLANE IV
Concentrations beyond 65-85% Light anesthesia contact with patient is lost

Indi

ti ns

Contr indi tions Nitrous oxide/oxygen sedation should not be used in

 

re-co-operative children atients ith upper air ay problems as common cold, tonsillitis or nasal blockage atients ith sinusitis or recent NT operations ( ithin days) atients in bleomycin chemotherapy (3 ) sychotic patients atients ith porphyria

Nitrous oxide/oxygen sedation is useful in children years and older. urther to the general indications for conscious sedation mentioned previously, nitrous oxide/oxygen can be used in patients ith a strong gagging reflex, hich makes dental treatment impossible, as ell as in patients ith muscular tone disorders such as cerebral palsy, in order to avoid unintentional movements. atients belonging to ASA Class III and Class IV can be treated ith the help of nitrous oxide/oxygen sedation provided other indications are present, but treatment of these patients must be restricted to hospital settings, here an anaesthesiologist can be present.

SIDE EFFECTS

Nausea/Vomiting Pain in patients with otitis media Toxicity with prolonged exposure

Indications and benefits

Rapid onset of action Reliable

Limitations and risks

Children are not compliant Injury during drug administration Limited control

Drugs commonly used

Ketamine Midazolam

Easiest, most safest and efficient route after inhalation Indications and benefits
Rapid onset (20-25 seconds) Suitable for apprehensive preteens and adolescent patients

Limitations and risks

Venipuncture is difficult to achieve in very young patients Poor patients compliance

Hematoma Only done by extensively trained operator Irreversible effect

Drugs commonly used

Midazolam Propofol

Only sublingually absorbed drugs are administered Advantage

Rapid onset of action compared to oral

Disadvantage

Does not go through first pass effect Poor patients compliance

Drugs

used

Lorazepam Triazolam

 Indications

and benefits

Bitter oral drugs

Limitations

and risks

Inconvenience Mucosal irritation Partial first pass effect Discomfort

Drugs

used

Rectal Chloral Hydrate Thiopental Rectal Midazolam

Involves squirting a concentrated form of a sedative drug up the nose. Indications and benefits
Afraid of needles Special needs

Rapid absorption Rapid onset

Limitations and risks

Difficult to determine drug dosage Mucosal irritation

Drugs used

Midazolam Sufentanil Ketamine

Deposition of drug beneath the mucosa Fast onset May cause mucosal irritation Drugs used

Fentanyl Meperidine