Sedación Oral Consciente en Cirugía Ortognática

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Protocolo estandarizado de sedación oral consciente.Las drogas más comúnmente empleada son las benzodiacepinas, La más usada de todas para sedación-anlagesia es el Midazolam (Doricum,Dormicum,Versec)

Con mucha frecuencia los pacientes son sometidos a procedimientos "menores", muchos de ellos dolorosos, sin sedación o analgesia.

El dolor y la ansiedad deben ser abolidos, no solo por razones éticas y humanitarias, sino también para evitar la respuesta fisiopatológica al dolor.

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  • Routine dental and maxillofacial surgery are commonly undertaken on a day case basis. Pain and anxiety are the most common complaints referred by patients Analgesia and Anxiolysis: are mandatory for today’s practice Health professionals have used oral medications for many years to relieve fear and apprehension associated with dental and medical treatments Oral premedication and sedation with benzodiazepines are widely used in Medicine
  • The purpose of this paper is to assess the safety and effectiveness of an oral anxiolysis sedation protocol for adults by means of an initial standardized midazolam dose for dental treatments and ambulatory maxillofacial surgery.
  • Multiple centers retrospective study conducted from 1998 to 2004
  • A total of 343 patients were included in the study, 260 females and 83 males.
  • The mean age was 23.5 years
  • mean weight was 69.6 Kgs
  • Every patient was evaluated considering risk factors and underwent a complete medical physical examination. 295 ASA I 48 Asa II ASA II Hipertention 32 Diabetes were the pathologies in the asa II group
  • The patients were referred for oral and cosmetic surgery
  • All the surgical units and surgeons had the same protocols in terms of
  • fear, stress and anxiety were the mainly reason to indicate the protocol
  • All the patients underwent a complete physical and medical evaluation and special attention was given to the no liquid intake 4 hours prior the surgery and no solid intake 6 hour prior the surgery
  • All the surgical units have the same monitoring capabilities
  • Heart rate and oxygen saturation were continuously monitored. Respiratory rate and blood pressure were monitored and documented every 5 minutes Length and type of surgery were recorded.
  • All considerations were taken to discharge the patient fully stable
  • Post sedation indication are given to the person in charge of the patient, outside the surgical facilities
  • The anxiolysis sedation protocol consists in two phases, oral premedication 90 minutes prior to the surgery (midazolam 7,5 mg, unique dose) and posterior oral sedation (midazolam, 0.20 mg/kg) 30 minutes prior to the anaesthesia infiltration.
  • Anxiety control is one of the aim variables to measure and record Levels of anxiety are addressed 30 minutes pre-operative , immediate post-operatively and at the moment to discharge the patient
  • The anxiety scale that we use gives points to the level of anxiety at 3 different moments with special attention in the effectiveness of the drug
  • In terms of 87 % of the patients, no to mild anxiety was referred, 30 minutes prior to surgery
  • The anxiety at the end of the surgery shows an increase in the levels, in the moderate but tolerated group and in the not controlled group
  • Levels of anxiety and effectiveness of the medication after 1 hour showed that 96 % of the patients were among the no anxiety or tolerable groups and only 4 % were unsatisfied with the protocol medication proposed
  • Sedación Oral Consciente en Cirugía Ortognática

    1. 1. STANDARDIZED PROTOCOL FOR THE USE OF ORAL MIDAZOLAM Dr. Samuel Benarroch MD, DDS, MS Assistant Professor Oral & Maxillofacial Surgery Residency Program Woodhull Medical Center. New York Hospital Magallanes de Catia. Caracas
    2. 2. ANXIOLYSIS & SEDATION
    3. 3. PURPOSE Assess the safety and effectiveness of an oral anxiolysis sedation protocol for adults by means of a standardized midazolam dose for dental treatments and ambulatory maxillofacial surgery
    4. 4. DESIGN <ul><li>Multiple centers </li></ul><ul><li>Retrospective study </li></ul><ul><li>Conducted from 1998 to 2004 </li></ul>
    5. 5. PATIENT DISTRIBUTION SEX SEX NUMBER % MALE 83 24.20 FEMALE 260 75.80 TOTAL 343 100
    6. 6. PATIENT DISTRIBUTION AGE AGE NUMBER % 15 – 20 138 40.23 21 – 30 163 47.29 31 – 40 28 8.05 41 – 50 8 2.47 > 50 6 2.05 TOTAL 343 100
    7. 7. PATIENT DISTRIBUTION WEIGHT WEIGHT NUMBER % 55 – 59 43 12.5 60 – 64 128 37.3 65 – 69 94 27.4 70 – 74 49 14.3 > 75 29 8.5 TOTAL 343 100
    8. 8. PATIENT DISTRIBUTION Physical Status Classification ASA NUMBER % ASA I 295 75.80 ASA II 48 24.20 TOTAL 343 100
    9. 9. PATIENT DISTRIBUTION SURGICAL PROCEDURES PROCEDURE NUMBER % ORAL SURGERY 329 95.92 COSMETIC SURGERY 14 4.08 TOTAL 343 100
    10. 10. PATIENT DISTRIBUTION ORAL SURGERY
    11. 11. PATIENT DISTRIBUTION ORAL SURGERY
    12. 12. PATIENT DISTRIBUTION ORAL SURGERY PROCEDURES NUMBER % THIRD MOLAR EXTRACTION 4 180 54.7 MULTIPLES DENTAL EXTRACTIONS 45 13.7 MULTIPLE IMPLANTS SURGERY 67 20.4 PREPROSTHETIC SURGERY 24 7.2 OTHER 13 4 TOTAL 329 100
    13. 15. PATIENT DISTRIBUTION COSMETIC SURGERY
    14. 16. PATIENT DISTRIBUTION COSMETIC SURGERY
    15. 17. PATIENT DISTRIBUTION COSMETIC SURGERY
    16. 18. PATIENT DISTRIBUTION COSMETIC SURGERY PROCEDURES NUMBER % GENIOPLASTY 7 50.3 RHINOPLASTY 3 21.3 BLEPHAROPLASTY 2 14.2 FACIAL LIPOSUCTION 1 7.1 Mini lifting 1 7.1 TOTAL 14 100
    17. 19. PROTOCOLS <ul><li>Oral anxiolysis sedation indications </li></ul><ul><li>Patient assessment </li></ul><ul><ul><li>ASA I or II </li></ul></ul><ul><ul><li>Weight up 55 Kgs </li></ul></ul><ul><ul><li>Minimal Monitoring equipments </li></ul></ul><ul><li>Medications </li></ul><ul><li>Anxiolysis sedation management </li></ul><ul><ul><li>monitoring and documentation of the procedure </li></ul></ul><ul><ul><li>discharge criteria </li></ul></ul><ul><ul><li>Post sedation instructions </li></ul></ul>
    18. 20. ORAL ANXIOLYSIS SEDATION INDICATION <ul><li>Fear, Stress and Anxiety about having a dental treatment or oral and maxillofacial surgery </li></ul><ul><li>History of bad dental or surgical experiences </li></ul><ul><li>Low Pain threshold </li></ul><ul><li>Long dental or surgical appointments </li></ul>
    19. 21. PATIENT EVALUATION <ul><li>1. Physical status assessment (review of systems, vital signs, airway, cardiopulmonary reserve). </li></ul><ul><li>2. Past and present drug history including drug allergies. </li></ul><ul><li>3. Previous adverse experience with sedation and analgesia as well as with regional and general anesthesia. </li></ul><ul><li>4. Results of relevant diagnostic studies. </li></ul><ul><li>5. History of tobacco, alcohol, and substance use/abuse. </li></ul><ul><li>6. Verification of patient NPO status. </li></ul><ul><li>7. Plan and choice of sedation. </li></ul><ul><li>8. Transportation arrangements for patients who are expected to be discharged from the facility. </li></ul>
    20. 22. MONITORING EQUIPMENTS <ul><li>1. A self-inflating positive-pressure oxygen delivery system capable of administering oxygen </li></ul><ul><li>2. Appropriate sizes of airway management equipment (e.g., masks, oral airways, endotracheal tubes, and laryngoscopes). </li></ul><ul><li>3. A suction apparatus with catheters and Yankauer-type rigid suction device. </li></ul><ul><li>4. Monitors including those capable of measuring: </li></ul><ul><ul><ul><li>A. Oxygenation (pulse oximeter) </li></ul></ul></ul><ul><ul><ul><li>B. Blood Pressure (automated or manual device) </li></ul></ul></ul><ul><ul><ul><li>C. Heart Rate </li></ul></ul></ul><ul><li>5. Telephone or other device capable of summoning assistance in an emerge </li></ul>
    21. 23. MONITORING OF THE PROCEDURE <ul><li>Baseline vital signs shall be recorded in the sedation record before administering sedation and analgesia. </li></ul><ul><li>During sedation , the following vital signs shall be monitored and documented in the sedation record with 5 minute intervals : </li></ul><ul><ul><li>Heart rate - continuous monitoring . This must be done by ECG in all patients with cardiac or pulmonary disease, and may be monitored by pulse oximetry in all other patients. </li></ul></ul><ul><ul><li>Respiratory rate </li></ul></ul><ul><ul><li>Oxygen saturation (pulse oximeter) - continuous monitoring </li></ul></ul><ul><ul><li>Blood Pressure </li></ul></ul>
    22. 24. DISCHARGE CRITERIA PROTOCOL <ul><li>Patient is easily awakened by normal or softly spoken verbal commands. </li></ul><ul><li>Patient is oriented when awake as appropriate for age. </li></ul><ul><li>All vital signs are stable </li></ul><ul><li>There is no significant risk of losing protective reflexes. </li></ul><ul><li>Patient is able to maintain pre-procedure mobility with minimal assistance as appropriate for the procedure. </li></ul><ul><li>Minimal nausea and/or dizziness </li></ul>
    23. 25. POST SEDATION INSTRUCTIONS <ul><li>1 . Information about expected behavior following sedation. </li></ul><ul><li>2. Instructions for eating. </li></ul><ul><li>3. Warning signs of complications. </li></ul><ul><li>4. Special instructions in case of emergency. </li></ul><ul><li>5. A telephone number to contact the medical service responsible for the patient’s care that is available 24 hours per day. </li></ul><ul><li>6. A notation shall be placed in the medical record that instructions were received and understood by a responsible person or adult patient </li></ul>
    24. 26. MEDICATIONS MIDAZOLAM <ul><li>Initial dose 7.5 mg, 90 minutes prior to the surgery </li></ul><ul><li>Subsequent dose 0.20 mg/kg, 30 minutes prior to start the anesthesia infiltration </li></ul>
    25. 27. LEVELS OF ANXIETY <ul><li>Pre-operative </li></ul><ul><li>Post operative </li></ul><ul><ul><li>Immediate </li></ul></ul><ul><ul><li>Discharge from clinic </li></ul></ul>
    26. 28. ANXIETY MESUREMENTS <ul><li>HEART RATE </li></ul><ul><li>DIAPHORESIS </li></ul><ul><li>ANXIETY SCALES </li></ul>
    27. 29. ANXIETY SCALE <ul><li>No anxiety 1 </li></ul><ul><li>Mild anxiety but tolerable 2 </li></ul><ul><li>Moderate anxiety but tolerated 3 </li></ul><ul><li>Moderate anxiety not controlled by prescribed drug 4 </li></ul><ul><li>Severe anxiety not controlled by prescribed drug 5 </li></ul>
    28. 30. RESULTS <ul><li>54.7 % molar extraction and 13.7 multiples extraction </li></ul><ul><li>The length of surgical time ranged from 13-65 minutes (mean time of surgery at 39.4 minutes). </li></ul><ul><li>312 cases (91%) surgery lasting less than 50 minutes </li></ul><ul><li>No extra midazolam doses were necessary in any patient </li></ul><ul><li>The mean heart rate and respiratory rate were within acceptable clinical limits. The lowest mean arterial oxygen saturation levels were 95 %, 75% had partial amnesia. </li></ul><ul><li>Midazolam (second phase) sedation lasted about 55-65 minutes, producing good operating conditions and stable vital signs with adequate verbal response. </li></ul><ul><li>The main adverse effects were drowsiness and dizziness on the same day </li></ul>
    29. 31. PRE SURGERY ANXIETY CONTROL 30 minutes prior to surgery <ul><li>No anxiety 64.6 % </li></ul><ul><li>  Mild anxiety but tolerable 22.5 % </li></ul><ul><li>  Moderate anxiety but tolerated 10.3 % </li></ul><ul><li>  Moderate anxiety not controlled by prescribed drug 1.6 % </li></ul><ul><li>Severe anxiety not controlled by prescribed drug 1.0 % </li></ul>
    30. 32. POST SURGERY IMMEDIATE ANXIETY CONTROL 10 minutes after surgery No anxiety 56.4 %   Mild anxiety but tolerable 18.5 %   Moderate anxiety but tolerated 16.9 %   Moderate anxiety not controlled by prescribed drug 5.1 % Severe anxiety not controlled by prescribed drug 3.1%
    31. 33. ANXIETY CONTROL POST SURGERY 1 HOUR <ul><li>No anxiety 44.7 % </li></ul><ul><li>Mild anxiety but tolerable 20.6 % </li></ul><ul><li>  Moderate anxiety but tolerated 31.7 % </li></ul><ul><li>  Moderate anxiety not controlled by prescribed drug 1.6 % </li></ul><ul><li>Severe anxiety not controlled by prescribed drug 1.4 % </li></ul>
    32. 34. Conclusions <ul><li>The protocol proposed is a simple, safe, effective, and practical approach in the preoperative anxiety management in ambulatory patients </li></ul><ul><li>Adequate patient comfort and cooperation is accomplished with minimal invasiveness and no adverse effects </li></ul><ul><li>The Oral midazolam protocol may provide an alternative to other procedures </li></ul><ul><li>Cost effective </li></ul><ul><li>Easy to use by medium trained personnel </li></ul>
    33. 35. THANK YOU STANDARDIZED PROTOCOL FOR THE USE OF ORAL MIDAZOLAM Dr. Samuel Benarroch MD, DDS, MS Assistant Professor Oral & Maxillofacial Surgery Residency Program Woodhull Medical Center. New York Hospital Magallanes de Catia. Caracas

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