Sedation and general anesthesia in dentistry
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Sedation and general anesthesia in dentistry

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Sedation and general anesthesia in dentistry

Sedation and general anesthesia in dentistry

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Sedation and general anesthesia in dentistry Sedation and general anesthesia in dentistry Presentation Transcript

  • Sedation and General Anesthesia in Dentistry Assistant professor : Akram Thabet Nasher B.D.S, M.Sc. , Ph.D. Head department of oral and maxillofacial surgery Faculty of Dentistry- Sana`a university
  • Anesthesia  The practice psychological, approaches of physical, to the and various chemical prevention and treatment of preoperative, operative, and postoperative anxiety and pain. Sedation and General Anesthesia Dr.Akram Thabet
  • Levels of Anesthesia  Local anesthesia  Conscious Sedation  Deep Sedation  General Anesthesia Sedation and General Anesthesia Dr.Akram Thabet
  • Local Anesthesia Local, or regional, anesthesia involves the injection or application of an anesthetic drug to a specific area of the body. It eliminates sensation and pain in a local area of the body without loss of consciousness. Sedation and General Anesthesia Dr.Akram Thabet
  • According to the degree of CNS depression: ◦ Conscious Sedation ◦ Deep Sedation ◦ General Anesthesia Sedation and General Anesthesia Dr.Akram Thabet
  • Sedation  It is a technique where one or more drugs are used to depress the Central Nervous System of a patient thus reducing the awareness of the patient to his surrounding. Sedation and General Anesthesia Dr.Akram Thabet
  • Conscious Sedation  It is a controlled, pharmacologically Induced, minimally depressed level of consciousness that retains the patient’s ability to maintain independently and a patent continuously airway and respond appropriately to physical and/or verbal command.  ventilatory and cardiovascular functions are unaffected Sedation and General Anesthesia Dr.Akram Thabet
  • Deep Sedation It is a controlled, pharmacologically induced state of depressed level of consciousness , from which the patient is not easily aroused and which may be accompanied by a partial loss of protective reflexes, including the ability to maintain a patent airway independently and/or respond purposefully to physical stimulation or verbal commands. Sedation and General Anesthesia Dr.Akram Thabet
  • General Anesthesia  The elimination of all sensations accompanied by the loss of consciousness.  Sometimes, the two phrases (GA & Deep Sedation) refer to one physiologic state. Sedation and General Anesthesia Dr.Akram Thabet
  • Sedation and General Anesthesia Dr.Akram Thabet
  • Sedation and General Anesthesia Dr.Akram Thabet
  • Risks of Anesthesia high Deep Sedation General Anesthesia Conscious Sedation Local Anesthesia Anxiolysis low N20 Sedation and General Anesthesia Dr.Akram Thabet
  • Fundamental Concepts:  It is easy to drift from one state to another.  Any anesthetic/sedative/opioid regardless of route of administration can be a general anesthetic (can cause unconsciousness)  Patient state is considered in terms of the level of consciousness rather than the technique involved.  Sedation techniques techniques. are not pain-control Sedation and General Anesthesia Dr.Akram Thabet
  • Indications: 1- Behaviorally challenged patients (stressful and fearful patients). 2- Young children 3- Mentally retarded Patients 4- Major operations in oral and maxillofacial surgery 5- Stressful Procedure ( multiple 3 rd Molar extractions, Interosseous implants ,complex periodontal surgery) 6- Gagging reflexes 7- Local Anesthesia problems 8- Medically compromised patients Sedation and General Anesthesia Dr.Akram Thabet
  • Routes of Administration:      Enteral – any technique of administration in which the agent is absorbed through the gastrointestinal (GI) tract or oral mucosa [i.e., oral, rectal, sublingual]. Parenteral – a technique of administration in which the drug bypasses the gastrointestinal (GI) tract [i.e., intramuscular (IM), intravenous (IV), intranasal (IN), submucosal (SM), subcutaneous (SC), intraosseous (IO)]. Transdermal – a technique of administration in which the drug is administered by patch or iontophoresis through skin. Transmucosal – a technique of administration in which the drug is administered across mucosa such as intranasal, sublingual, or rectal. Inhalation – a technique of administration in which a gaseous or volatile agent is introduced into the lungs and whose primary effect is due to absorption through the gas/blood interface. Sedation and General Anesthesia Dr.Akram Thabet
  • Sedation
  • Cons. Sedation  Minimally Depressed Consciousness Deep Sedation Deeply depressed consciousness  Anxiolysis  Sleeplike state  Interactive  Non-Interactive  Arousable  Non- arousable (except with tense stimulation)  Airway is maintained  Inability to maintain airway  Protective reflexes are intact  Partial loss of reflexes  Responses to command are intact  Difficult to respond to command Sedation and General Anesthesia Dr.Akram Thabet
  • Sedation techniques  Non - titrable Technique Oral Sedation Rectal Sedation Intramuscular Sedation Submucosal Sedation Intranasal Sedation  Titrable Technique Inhalational Sedation Intravenous Sedation  Combination Of the two Sedation and General Anesthesia Dr.Akram Thabet
  • I- Oral Sedation By far, it is the most universally accepted and easiest method of sedation administration.  The most variable (non-titrable) technique  Recovery time prolonged  Difficult to reverse unwanted effect  Utilizing escort  No repeated doses Sedation and General Anesthesia Dr.Akram Thabet
  • Advantages of Oral Sedation Universal acceptability  Ease of administration  Low cost  Incidence of adverse reactions less than some other techniques  No needles, syringes or special techniques  Various drugs, dosage forms available  Allergic reactions less severe than seen in parenteral administration  No specialized training  Sedation and General Anesthesia Dr.Akram Thabet
  • Disadvantages of oral Route  Reliance on patient cooperation  Prolonged onset  Erratic absorption, unpredictable effect  Inability to titrate to effect  Inability to readily lighten or deepen  Prolonged duration of effect  Adverse interactions of sedative drugs Sedation and General Anesthesia Dr.Akram Thabet
  • Contraindications to oral Sedation  Severe dental anxiety & fear  High probability of adverse drug interaction  Poor past experience with oral sedation  Allergy to drug being used  Other drug contraindications (pregnancy , glaucoma, etc.)  Need for rapid onset and/or rapid recovery Sedation and General Anesthesia Dr.Akram Thabet
  • Factors Influencing Oral Drug Absorption  Lipid solubility  pH of gastric tissues  Mucosal surface area  Gastric emptying time  Dosage form of drug  Drug inactivation (“first pass effect”)  Presence of food in stomach  Bioavailability of drug  Genetics Sedation and General Anesthesia Dr.Akram Thabet
  • II- Inhalational Sedation  Nitrous oxide/oxygen inhalation sedation is the most commonly used technique in dentistry for sedation .  Nitrous oxide/oxygen (N²O/O²) sedation is a combination of these gases that the patient inhales to help eliminate fear and to help the patient relax. Sedation and General Anesthesia Dr.Akram Thabet
  • Equipments  Continuous flow design with flow meters  Safe delivery of O2 and N2O.  Pin-indexed yoke system  Efficient scavenger Sedation and General Anesthesia Dr.Akram Thabet
  • Nasal Mask Sedation and General Anesthesia Dr.Akram Thabet
  • Advantages of Nitrous Oxide Rapid onset (almost equal to that of IV. administration )  Ability to titrate & to reverse  Depth of sedation readily altered  Flexible duration of action  Rapid recovery from sedation  Safe  No injection required  Very few side effects  No adverse effects on vital organs  Patient can be discharged alone  Non addictive.  Produces stage I anesthesia.  Dulls the perception of pain. Sedation and General Anesthesia  Dr.Akram Thabet
  • Disadvantages of Nitrous Oxide  Initial cost of cumbersome equipment is high  Continuing costs of gases high  Equipment takes up operatory space  Requires constant patient cooperation  Chronic exposure of office personnel can cause Carcinogenicity , Teratogenicity or Toxicity  Not always effective Sedation and General Anesthesia Dr.Akram Thabet
  • Relative Contraindications to Inhalation Sedation:          Severe dental anxiety & fear Compulsive personalities Poor past experience with oral sedation Pregnancy URI, COPD Nasal obstruction: Problems inhaling through the nose Emphysema: Increased O² Multiple sclerosis: Breathing difficulties Emotional stability: Altered perception of reality Sedation and General Anesthesia Dr.Akram Thabet
  • Potential Problems  Diffusion hypoxia  Vomiting  Toxicity: inhibit vitamin B12 dependent enzymes (Pernicious anemia) Reproductive Abnormalities Sedation and General Anesthesia Dr.Akram Thabet
  • Administration of Inhalation sedation Start with pure oxygen while establishing the patient’s tidal volume.  Slowly titrate the nitrous oxide until the desired results are achieved.  Patients should refrain from talking or mouth breathing.  The N²O/O² analgesia should end with the administration of 100% O² for 3 to 5 minutes.  Obtain postoperative vital signs and compare them to the preoperative recordings.  Sedation and General Anesthesia Dr.Akram Thabet
  • How to reduce N²O hazards to dental personnel ?? ◦ Use a scavenger system. ◦ Use a patient mask that fits well. ◦ Discourage patients from talking. ◦ Vent gas outside the building. ◦ Routinely inspect equipment and hoses for leaks. ◦ Use an N²O monitoring badge system. Sedation and General Anesthesia Dr.Akram Thabet
  • III- Intravenous Sedation  Antianxiety drugs that are administered intravenously continuously throughout the procedure at a slower rate, providing a deeper stage I analgesia.  The most rapid technique; onset approximately 20 to 25 seconds.  In children under 6 years, the incidence of untoward effects is increased Sedation and General Anesthesia Dr.Akram Thabet is
  • Drugs for sedations :  Either one drug or combinations of IV drugs  Commonest combinations Benzodiazepines & opioids Propofol & opioids Sedation and General Anesthesia Dr.Akram Thabet
  • Valium (Diazepam) Benzodiazepine  Produces sleepiness and relief of apprehension  Onset of action 1-5 minutes  Half-life  ◦ 30 hours ◦ Active metabolites  Average sedative dose ◦ 10-12 mg Sedation and General Anesthesia Dr.Akram Thabet
  • Versed (Midazolam)  Short acting benzodiazepine ◦ 4 times more potent than Valium Produces sleepiness and relief of apprehension  Onset of action 3-5 minutes  Half-life  ◦ 1.2-12.3 hours  Average sedative dose ◦ 2.5-7.5 mg Sedation and General Anesthesia Dr.Akram Thabet
  • Demerol (Meperidine)      Narcotic Pain attenuation and some sedation Onset of action ◦ 3-5 minutes Half-life ◦ 30-45 minutes Average dose ◦ 20-50 mg Sedation and General Anesthesia Dr.Akram Thabet
  • Fentanyl (Sublimaze)  Narcotic/Opiod agonist ◦ 100 times more potent than Morphine Pain attenuation and some sedation  Onset of action around 1 minute  Half-life  ◦ 30-60 minutes  Average dose ◦ 0.05 – 0.06 mg Sedation and General Anesthesia Dr.Akram Thabet
  • Additional Medications  Likely to be seen in scenarios where deeper levels of sedation are being performed ◦ Propofol (Diprivan) ◦ Robinul (Glycopyrrolate) Sedation and General Anesthesia Dr.Akram Thabet
  • Propofol (Diprivan) Intravenous anesthetic/sedative hypnotic  Sedative, anesthetic and some antiemetic properties  Onset of action within 30 seconds  Half-life  ◦ 2-4 minutes  Average sedative dose ◦ Varies Sedation and General Anesthesia Dr.Akram Thabet
  • Robinul (Glycopyrrolate)  Anticholinergic ◦ Heart rate increases ◦ Salivary secretions decrease Dose 0.1-0.2 mg  Onset of action within 1 minute  Sedation and General Anesthesia Dr.Akram Thabet
  • General anesthesia
  • Stages of General Anesthesia Stage I “Conscious Sedation” ◦ Analgesia  Stage II ◦ Delirium Stage III (“Deep Sedation/General Anesthesia) ◦ Surgical anesthesia  Stage IV ◦ Medullary paralysis  Sedation and General Anesthesia Dr.Akram Thabet
  • Four Stages of Anesthesia:  Stage I: Analgesia is the stage at which a patient is relaxed and fully conscious. The patient is able to keep his or her mouth open without assistance and is capable of following directions. The patient will have a sense of euphoria and a reduction in pain. Vital signs are normal. Depending on the agent used, the patient can move into different levels of analgesia. Sedation and General Anesthesia Dr.Akram Thabet
  •  Stage II: Excitement is the stage at which a patient is less aware of his or her immediate surroundings and can start to become unconscious. The patient can become excited and unmanageable. Nausea and vomiting can occur. This is an undesirable stage. Sedation and General Anesthesia Dr.Akram Thabet
  •  Stage III: This stage of General anesthesia in which the patient becomes calm after stage II. This is the favorable stage for doing surgery. The patient feels no pain or sensation. The patient will become unconscious. This stage of anesthesia can be met only under the guidance of an anesthesiologist in a controlled environment such as a hospital. Sedation and General Anesthesia Dr.Akram Thabet
  •  Stage IV: Respiratory failure or cardiac arrest is the stage at which the lungs and heart slow down or stop functioning. If this stage is not reversed quickly, the patient will die. Sedation and General Anesthesia Dr.Akram Thabet
  • Intubation in GA. For maintenance of respiration : Sedation and General Anesthesia Dr.Akram Thabet
  • Sedation and General Anesthesia Dr.Akram Thabet
  • Types of General Anesthetics  Induction agents( begins the anesthesia) ◦ Induction agents usually administered IV ◦ can be inhalational for those who do not tolerate IV access  Maintenance anaestheisa) agents (maintain the ◦ Maintenance agents usually administered inhalationally or IV with bolus or continuous infusion technique Sedation and General Anesthesia Dr.Akram Thabet
  • Routes for Delivery of General Anesthetics  Intravenous (IV)  Inhalational Sedation and General Anesthesia Dr.Akram Thabet
  • Structural formulas of anesthetic drugs. Sedation and General Anesthesia Dr.Akram Thabet
  • General Anesthetics-Intravenous Agents       Primary role as induction agents Maintenance with total intravenous anesthesia ◦ Rapid redistribution ◦ Shorter half lives ◦ Environmental risk of inhalational agents Rapid distribution to vessel rich tissues High lipid solubility allows for rapid induction When redistributed out of the brain, the effect decreases Advantages ◦ Rapid and complete induction ◦ Less CV depression Sedation and General Anesthesia Dr.Akram Thabet
  • General Anesthetics-Intravenous Agents The most commonly drugs used in GA: 1- Benzodiazepines 2- Opioids 3- Ketamine 4- Methohexital 5- Propofol  Sedation and General Anesthesia Dr.Akram Thabet
  • General Anesthetics-Inhalational Agents 1- Nitrous Oxide 2- Sevoflurane 3- Desflurane 4- Isoflurane (Forane) 5- Halothane Sedation and General Anesthesia Dr.Akram Thabet
  • Technician Responsibilities
  • Pre‐anesthetic Evaluation  “Never treat a stranger”  Never do anesthesia on a patient you have not previously evaluated.  Never sedate or aesthesis on first patient visit  Always have a consultation first! Sedation and General Anesthesia Dr.Akram Thabet
  • Pre‐anesthetic Examination         Physical examination Evaluation of anxiety level Review of medical history Review medications and drug allergies Assign ASA classification Review prior sedation / anesthetic history Obtain informed consent Give pre‐sedation/ anesthesia instructions Sedation and General Anesthesia Dr.Akram Thabet
  • Medical history Diseases to evaluate: HTN;, asthma, COPD, URI, DM  Pregnancy; psychiatric renal; hepatic problems  Obesity; sleep apnea; etc  Medications  Prior anesthetic experience  Allergies  Hospitalizations  Sedation and General Anesthesia Dr.Akram Thabet
  • Physical Examination Vital signs  Appearance  Height, Weight, & BMI (Body Mass Index)  Mental & psychological status  Cardiac & pulmonary level ;  Exercise tolerance (“if they can walk up 2 flights of stairs to your office, they’re probably ok for anesthesia”)  Airway evaluation  Sedation and General Anesthesia Dr.Akram Thabet
  • Airway Evaluation       BMI (Body Mass Index) History of obstructive sleep apnea, snoring Mallampati score Protrusive (ask: “bite your upper lip with your lower teeth”) TMJ range of motion (oral opening) Neck circumference Sedation and General Anesthesia Dr.Akram Thabet
  • Airway patency Sedation and General Anesthesia Dr.Akram Thabet
  • ASA Physical Classification  IA normal healthy patient  II A patient with mild systemic disease  III A patient with severe systemic  IVA patient with severe systemic disease that is a constant threat to life  VA moribund patient who is not expected to survive without the operation Sedation and General Anesthesia Dr.Akram Thabet
  • Pre-Procedure Patient Assessment ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ Investigations : ECG, echo Chest – x-ray CBC BT,CT ,PT T, PT ,INR Na , k R.B.S or F.B.S LFT KFT HBs-Ag HIV Sedation and General Anesthesia Dr.Akram Thabet
  • Medical Consultations  After doing the medical and physical examination with the full investigations; the patient should be evaluated by a medical doctor or anesthetist to do a medical fitness for him to receive the anesthesia. Sedation and General Anesthesia Dr.Akram Thabet
  • Informed Consent       It’s a process, not a piece of paper. Verbal and written informed consent must be given at the pre‐op consultation appointment, not the day of surgery Cannot be obtained once medications are administered. New written consent must be obtained for each procedure or sedation. Consent to surgery does not imply consent for sedation; sedation needs to be specified. Consent must be obtained by the doctor in face‐to‐face meeting, not a staff member. Sedation and General Anesthesia Dr.Akram Thabet
  • Pre‐Sedation/anesthetic Instructions  Give both verbally and in writing  Fasting (“NPO”) instructions (if needed)  “Vested” escort to accompany patient Patient’s other medications  Sedation and General Anesthesia Dr.Akram Thabet
  • Pre‐Procedure Fasting (“NPO”)  The patient must be fasted minimum 2-3 hours for clear liquids and 6 hours for solid food to prevent vomiting causing Suffocation and aspiration pneumonia. Sedation and General Anesthesia Dr.Akram Thabet
  • Psychological preparation  Psychological preparation of the patient for the sedation or GA is paramount.  Explain the different types of sedation available and GA techniques  Tell them they will be “relaxed, drowsy, comfortable,” and “aware and in control.”  Give realistic expectations to patient and explain that every patient reacts differently, and they may need more / less medication or different technique at future appointments. Sedation and General Anesthesia Dr.Akram Thabet
  • Intraoperative Responsibilities ◦ Informed consent signed prior to sedation ◦ Name, dose, route and time of all medications documented ◦ Procedure begin and end times ◦ Prior adverse reactions ◦ Pre-medication time and effect ◦ Vital Signs  BP  Heart Rate  Respiratory Rate  Oxygen Saturation  Level of Consciousness Sedation and General Anesthesia Dr.Akram Thabet
  • Monitoring Level Of Consciousness  Clinical Observation  Pulse Oximetry  Pericardial/pretracheal Stethoscope  BP  ECG  Monitoring oxygenation  Sedation and General Anesthesia Dr.Akram Thabet
  • Sedation and General Anesthesia Dr.Akram Thabet
  • Recovery  Patients may continue to be at significant risk of developing complications after procedure is completed.  Decreased procedural stimulation, delayed drug absorption, and slow drug elimination, may contribute to residual anesthesia or sedation and respiratory depression during the recovery period.  Patient must be kept in office under observation until completely recovered. Sedation and General Anesthesia Dr.Akram Thabet
  • Post-operative Responsibilities ◦ Vital Signs at least every 5 minutes       BP Heart Rate Respiratory Rate Oxygen Saturation Level of Consciousness Sedated/ Anesthetized patients must be continuously monitored until discharged Sedation and General Anesthesia Dr.Akram Thabet
  • Recommended Alarm Limits Low High Systolic BP 85 150 Diastolic BP 50 100 Oxygen Saturation 92 100 Respiratory Rate 10 16 Heart Rate 60 90 Sedation and General Anesthesia Dr.Akram Thabet
  • Medical Emergency  Syncope  Laryngospasm  Hypoglycemia  Apnea  Hypotension  Myocardial infarction  Hypertension  Stroke  Bronchospasm Sedation and General Anesthesia Dr.Akram Thabet
  • Medical Emergency  Know how to prevent, recognize, and treat syncope (fainting) ◦ Supplemental O2 ◦ Elevation of lower extremities ◦ Trendelenburg  Be prepared to assist in airway management Sedation and General Anesthesia Dr.Akram Thabet
  • Emergency Drugs Flumazenil (Romazicon)  Naloxone (Narcan)  Esmolol (Brevibloc)  Ephedrine  Epinephrine  Atropine  Sedation and General Anesthesia Dr.Akram Thabet
  • Flumazenil (Romazicon)  Benzodiazepine antagonist ◦ Versed reversal agent  Initial dose – 0.2mg ◦ May repeat at 1 minute intervals to dose of 1mg Onset of action within 1-2 minutes  Must monitor for re-sedation  ◦ May be repeated at 20 minute intervals as needed Sedation and General Anesthesia Dr.Akram Thabet
  • Naloxone (Narcan)  Narcotic antagonist ◦ Fentanyl reversal agent  Initial dose – 0.4mg ◦ May repeat every 2-3 minutes at doses of 0.4-2mg  Monitor for re-sedation Sedation and General Anesthesia Dr.Akram Thabet
  • Esmolol (Brevibloc)  Antihypertensive  Beta blocker  Initial dose 0.25 –1.0 mg/kg over 30 seconds ◦ Short half-life of approximately 10 minutes Sedation and General Anesthesia Dr.Akram Thabet
  • Ephedrine  Used for hypotension  Sympathomimetic  Initial dose 5-10mg  Action may not be seen for several minutes Sedation and General Anesthesia Dr.Akram Thabet
  • Atropine  Significant bradycardia ◦ Slow heart beat or NO heartbeat  Anticholinergic  Initial dose 0.25 – 1.0 mg ◦ May repeat every 3-5 minutes ◦ Maximum total dose .03 mg/kg Sedation and General Anesthesia Dr.Akram Thabet
  • Epinephrine  True emergency medication  Administration should be preceded by activation of the emergency response system Sedation and General Anesthesia Dr.Akram Thabet
  • Discharge Criteria Vital signs normal (within 20% baseline)  Airway patency uncompromised  Patient awake, or awake on command  Can breathe deeply  Protective reflexes intact (can cough on command)  Adequate hydration, able to drink  Patient can speak normally  Patient can sit unaided  Patient can walk with minimal assistance  Responsible, “vested,” adult escort is available  No pain, no nausea or vomiting,  Sedation and General Anesthesia Dr.Akram Thabet
  • Post‐sedation Instructions Verbal and written instructions must be given to the escort upon discharge from the office  Should include: – Potential and anticipated post‐sedation effects –Limitation of activity (driving, machinery) x 24 hrs – Dietary precautions and suggestions – No other sedatives x 24 hrs – 24 hour contact number for practitioner  Sedation and General Anesthesia Dr.Akram Thabet
  • Thank You Sedation and General Anesthesia Dr.Akram Thabet