Sedation for-general-dentists
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In the hope that everyone benefits, I’d like to begin sharing a series of lectures that I have given over the years that would be of interest to all. I’ll limit lectures to those that I have given in front of audiences of several hundred, and ones that were well-received and are current. Hope that you enjoy, and that my lectures help you become a better provider!
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Sedation for-general-dentists
- 1. The Spectrum of Sedation in Dentistry: Oral Sedation to General Anesthesia George P. Hatzigiannis DMD, MD® George P. Hatzigiannis D.M.D., M.D.
- 2. George P. Hatzigiannis DMD, MD® Objectives of Sedation Prepare for safe administration of ambulatory anesthesia/sedation Understand relevant anatomy and physiology of target patient Appropriate patient selection Select appropriate modality and agents Prevent complications Manage complications
- 3. George P. Hatzigiannis DMD, MD® Objectives of Sedation Enable or bypass patient’s “coping” skills Use safe agents which minimize risk Use agents which are most effective Start when desired End when desired Affect anxiolysis, analgesia, and amnesia
- 4. George P. Hatzigiannis DMD, MD® Key Definitions Anxiolysis: diminution or elimination of anxiety Analgesia: diminution or elimination of pain Amnesia: diminution or elimination or memory
- 5. George P. Hatzigiannis DMD, MD®
- 6. George P. Hatzigiannis DMD, MD® Degree of Sedation Should be based on: The patient The procedure The doctor’s training and experience Range from no anesthesia to general anesthesia
- 7. George P. Hatzigiannis DMD, MD® (Light) Moderate (Conscious) Sedation Minimally depressed level of consciousness Retains ability to Independently and continuously maintain airway Respond appropriately to physical stimulation or verbal command
- 8. George P. Hatzigiannis DMD, MD® Deep Sedation Induced state of depressed consciousness Partial loss of protective reflexes Inability to continually maintain an airway independently and/or respond purposefully to physical stimulation or verbal command
- 9. George P. Hatzigiannis DMD, MD® General Anesthesia Induced state of unconsciousness Partial or complete loss of protective reflexes Inability to continually maintain an airway independently Inability to respond purposefully to physical stimulation or verbal command
- 10. George P. Hatzigiannis DMD, MD®
- 11. George P. Hatzigiannis DMD, MD® Objectives of Oral Sedation Reduce intra-operative anxiety Elevate pain threshold Maintain conscious, cooperative and comfortable state Attenuate autonomic responses Level of patient anxiety Management of mildly apprehensive patient
- 12. George P. Hatzigiannis DMD, MD® Oral Sedation: Advantages Simple & convenient Drugs readily available by prescription Drug reactions are generally less severe Medication may be administered pre-operatively Duration of action may extend into post- treatment
- 13. George P. Hatzigiannis DMD, MD® Oral Sedation: Disadvantages Dosages are largely empirical Titration to clinical endpoint impossible Erratic absorption makes response unpredictable Level of sedation cannot be altered Not useful in extremely apprehensive patient Duration of action may extend into post- treatment period
- 14. George P. Hatzigiannis DMD, MD® Intravenous Sedation: Advantages Rapid onset of action Titration is possible Highly effective Short recovery Venous access - benefit in emergency Little nausea and vomiting Control of saliva is possible Gag reflex diminished
- 15. George P. Hatzigiannis DMD, MD® Intravenous Sedation: Disadvantages Venipuncture necessary Venipuncture complications More intensive monitoring required Need escort for discharge, residual effect Some agents cannot be reversed
- 16. George P. Hatzigiannis DMD, MD® Intravenous Sedation: Contraindications Doctor training Pregnancy Significant hepatic disease Uncontrolled thyroid & adrenal dysfunction Medications such as MAOIs, TCAs, etc Extreme obesity and airway problems Lack of venous access Allergic reactions Illicit drug use - cocaine etc.
- 17. George P. Hatzigiannis DMD, MD® Conscious Sedation Deep Sedation General Anesthesia Consciousness Minimally depressed Depressed Unconscious Airway Independent, continuous Not continually independent Partial or complete inability Response Appropriate Purposeful Not responsive Anxiolysis ++++ ++++++ ++++++ Analgesia - - +/- Amnesia +/- +/- +/-
- 18. George P. Hatzigiannis DMD, MD® Pharmacology of Safe Drugs for the Dental Office Reminder: some drugs, by different routes or dosages, can be anxiolytic only or sedative only or, in some cases, general anesthetics Reminder: some drugs must always be treated AS IF they are general anesthetics General rule: more than one drug given means more than “conscious” sedation administered Exception: nitrous oxide + anxiolytic agent
- 19. George P. Hatzigiannis DMD, MD® Essential Concept of Rescue The practitioner must have the skills to rescue should the patient progress to a deeper level of sedation than intended
- 20. George P. Hatzigiannis DMD, MD® Patient Evaluation & Selection ASA I: Normal healthy patient ASA II: Patient with mild systemic disease and no functional limitations (includes extremes of age) ASA III: Patient with severe systemic disease that is not incapacitating ASA IV: Patient with incapacitating disease that is a constant threat to life ASA V: Moribund patient not expected to survive 24 hours with or without treatment ASA VI: Declared brain-dead patient being supported for organ donation
- 21. George P. Hatzigiannis DMD, MD® ASA Practice Guidelines: Preoperative Fasting Ingested material Minimum fast (hours) Clear liquids 2 Breast milk 4 Infant formula 6 Non-human milk 6 Light meal 6
- 22. George P. Hatzigiannis DMD, MD® Mallampati Classification
- 23. George P. Hatzigiannis DMD, MD® Office Personnel Number Enteral / “Conscious” Sedation: dentist + one Deep sedation / General anesthesia: dentist + two Qualifications Dentist/anesthetist: ACLS Remainder staff: BLS
- 24. George P. Hatzigiannis DMD, MD®
- 25. Monitoring George P. Hatzigiannis DMD, MD®
- 26. George P. Hatzigiannis DMD, MD® Monitoring Modalities Cardiovascular Rate Rhythm Pressure Respiratory Oxygenation Ventilation Temperature Urine output BIS monitor
- 27. George P. Hatzigiannis DMD, MD® Rationale for Monitoring Patients have systemic diseases which may require intervention Anesthetic agents alter physiologic function Example: depression of hypoxic and hypercapneic respiratory drive
- 28. George P. Hatzigiannis DMD, MD® Rationale for Monitoring Midazolam (.05 mg/kg) + fentanyl (2 µg/kg) Drugs Apnea Hypoxemia Midazolam 0% 0% Fentanyl 0% 50% Both 50% 90%
- 29. George P. Hatzigiannis DMD, MD® Monitoring without Automated Instrumentation Inspection Skin Surgical field Movement Body Chest Palpation Auscultation
- 30. George P. Hatzigiannis DMD, MD® Which monitors? Monitor Detect Event Pulse oximetry 82% Capnography 55% Pulse ox + capno 88% Pulse ox + capno + BP 93 Pulse ox + capno + BP + EKG 93.5%
- 31. George P. Hatzigiannis DMD, MD® Pulse Oximetry Measures sufficient saturation of oxygen in blood and peripheral perfusion Measures absorption of specific wavelengths of light Standard of care during anesthesia and the early postoperative period
- 32. George P. Hatzigiannis DMD, MD® Oxyhemoglobin Dissociation Curve
- 33. George P. Hatzigiannis DMD, MD® Pulse Oximetry Limitations Monitors peripheral versus central arterial oxyhemoglobin saturation Only measures end-point of adequacy of ventilation False readings: Hypothermia (shivering, vasoconstriction) Agitation Nail Polish Dysfunctional HgB
- 34. George P. Hatzigiannis DMD, MD® Capnography Continuous measurement of inhaled and exhaled concentrations of CO2 Measures adequacy of ventilation Standard of care when artificial airway is used
- 35. George P. Hatzigiannis DMD, MD® Capnography
- 36. George P. Hatzigiannis DMD, MD® Non-Intubated Capnography Nasal cannula or hood with sampling line Wave pattern more sensitive than pretracheal stethoscope Small diameter prongs and shorter cannula result in reliable measurements
- 37. George P. Hatzigiannis DMD, MD® Bispectral Index Monitor (BIS) Processed EEG from scalp electrodes that reflects sedative and hypnotic effects of drugs Index 1-100 70-80: eyelid ptosis <70: low risk recall <60: unresponsive Useful monitor for guiding drug administration, decreased recovery and intraoperative awareness
- 38. George P. Hatzigiannis DMD, MD® Monitoring Conclusions Minimum requirements based on Standard of Care Morbidity and mortality most frequently associated with respiratory depression or obstruction No equipment can replace the human element - integration and instantaneous adjustments
- 39. George P. Hatzigiannis DMD, MD®
- 40. Pharmacology George P. Hatzigiannis DMD, MD®
- 41. George P. Hatzigiannis DMD, MD® Prescribing an Oral Agent Written and oral instructions Consider a bedtime dose before the dental appointment Administer well in advance of need Patient accompanied by a responsible adult Prescribe only the amount of drug required Recovery & assistance required Sedation dosage only in office setting
- 42. George P. Hatzigiannis DMD, MD® Drugs for Oral Agents Benzodiazepines Histamine blocking agents Opioids
- 43. Benzodiazepines George P. Hatzigiannis DMD, MD®
- 44. George P. Hatzigiannis DMD, MD® Oral Benzodiazepines Drug Onset Elimination Adult Dosage Diazepam Rapid Slow 2-15 mg Triazolam Intermediate Rapid .125-.25 mg Lorazepam Intermediate Intermediate 1-4 mg Alprazolam Intermediate Intermediate .25-.5 mg Oxazapam Slow Rapid 10-15 mg
- 45. George P. Hatzigiannis DMD, MD® Mechanism of Action Enhances the chloride ion channel gating function of the inhibitory neurotransmitter GABA Results in hyperpolarization of cell membranes, making them more resistant to neuronal excitation GABA receptors exist almost exclusively in CNS
- 46. George P. Hatzigiannis DMD, MD® Benzodiazepine Effects Anxiolysis Anticonvulsant Sedation Amnesia Muscle relaxation Allergic reactions - nonexistent
- 47. George P. Hatzigiannis DMD, MD® Physiologic Effects Cardiovascular Slight decrease in SVR (decrease BP) Slight decrease myocardial contractility Respiratory Minimal depression of ventilation Minimal decrease in hypoxic/hypercapneic drive CNS Potent anticonvulsants
- 48. George P. Hatzigiannis DMD, MD® Midazolam Onset 3-8 minutes Duration 20-35 minutes Greater amnesia than diazepam Less pain than diazepam, lorazepam because water soluble
- 49. George P. Hatzigiannis DMD, MD® Diazepam Onset 1-3 minutes Duration 35-60 minutes More postoperative sedation than midazolam Drug of choice in abolishing seizure activity Pain and phlebitis more common Propylene glycol base
- 50. George P. Hatzigiannis DMD, MD® Reversal Flumazenil (Romazicon) - competitive inhibitor of GABA 0.2 mg IV over 15 seconds 0.1 mg IV bolus every 60 seconds to desired effect Duration is brief and may require repeat dose May induce seizures, acute withdrawal, nausea, dizziness, agitation, or arrhythmias
- 51. George P. Hatzigiannis DMD, MD®
- 52. Opioids George P. Hatzigiannis DMD, MD®
- 53. George P. Hatzigiannis DMD, MD® CNS Effects Analgesia, euphoria, sedation Feelings of heaviness, difficulty concentrating Apnea, inconsistent hypnosis Toxicity Dysphoria, agitation Seizures (esp meperidine) Can increase ICP
- 54. George P. Hatzigiannis DMD, MD® Physiologic Effects Cardiovascular Bradycardia, peripheral vasodilation, orthostatic hypotension Respiratory depression Blunt ventilatory response to CO2 Pupillary constriction (demerol dilation) Nausea & vomiting
- 55. George P. Hatzigiannis DMD, MD® Physiologic Effects Muscle rigidity Especially with large IV doses Can prevent ventilation in severe case Benzodiazepine pretreatment can minimize Histamine release Not fentanyl
- 56. George P. Hatzigiannis DMD, MD® Fentanyl 75-125x more potent than morphine Onset: 3.5-6 minutes Duration: 30-60 minutes Low dose (1-2 µg/kg) analgesia, high (2-20 µg/ kg) for intubation No histamine release Recurrent respiratory depression
- 57. George P. Hatzigiannis DMD, MD® Meperidine Depresses myocardial contractility Treats shivering Active metabolites Lower seizure threshold
- 58. George P. Hatzigiannis DMD, MD® Reversal Naloxone (Narcan) Pure opioid antagonist 1-4 µg/kg IV dose Adverse: Can activate the sympathetic nervous system, resulting in cardiovascular stimulation Reversal of analgesia
- 59. George P. Hatzigiannis DMD, MD®
- 60. Propofol George P. Hatzigiannis DMD, MD®
- 61. George P. Hatzigiannis DMD, MD® Propofol Highly lipid soluble Short duration of action (2-8 minutes) Hepatic metabolism Rapid recovery Reduction in blood pressure Profound respiratory depression Great antiemetic
- 62. George P. Hatzigiannis DMD, MD®
- 63. Ketamine George P. Hatzigiannis DMD, MD®
- 64. George P. Hatzigiannis DMD, MD® Ketamine “Dissociative anesthetic” Dissociates thalamus from limbic system Derivative of PCP (“angel dust”) Excellent analgesic and amnestic properties Potential for emergence delirium, minimized with benzos
- 65. George P. Hatzigiannis DMD, MD® Ketamine Positive sympathomimetic response Hypertension Tachycardia Maintains reflexes Minimal respiratory depression Profound bronchodilator
- 66. George P. Hatzigiannis DMD, MD®
- 67. Inhalational Anesthetics George P. Hatzigiannis DMD, MD®
- 68. George P. Hatzigiannis DMD, MD® Ideal Inhaled Anesthetic Sufficient potency Non-pungent No adverse respiratory complications No adverse cardiac complications Provide muscle relaxation Minimal metabolism No post-emergence side effects Reliable and simple delivery system Economical
- 69. George P. Hatzigiannis DMD, MD® Nitrous Oxide Safe, well-tolerated Wide safety margin MAC 104 Max dose 70% Reduced need for other meds Conscious sedation as sole agent, can be deep with multi-agents
- 70. George P. Hatzigiannis DMD, MD® Signs of Oversedation Persistent closing of mouth Incoherent speech or response Uncontrollable laughing Uncooperative Uncoordinated movements Sexual fantasies / hallucinations
- 71. George P. Hatzigiannis DMD, MD® Sevoflurane Rapid onset and recovery Minimally pungent Respiratory depression, bronchodilation Suitable for mask induction Reduce blood pressure, myocardial depression
- 72. George P. Hatzigiannis DMD, MD® Nausea / Vomiting Children > adults Females > males Obese > lean Perioperative anxiety Past history Motion sickness Head and neck surgery
- 73. George P. Hatzigiannis DMD, MD® Anesthetic Agents & PONV Emetic Antiemetic Opioids Steroids Ketamine Propofol Nitrous oxide Local anesthetic Methohexital IV fluids Oxygen Zofran
- 74. George P. Hatzigiannis DMD, MD®
- 75. Emergencies George P. Hatzigiannis DMD, MD®
- 76. George P. Hatzigiannis DMD, MD® Emergencies Respiratory events most common Respiratory events worst outcomes when not promptly treated Prevention is key
- 77. George P. Hatzigiannis DMD, MD® Common Emergencies Syncope: position/oxygen/ammonia/atropine Allergies: benadryl/epinephrine/steroid Seizures: position/oxygen/airway/benzo Nausea/vomiting: position/suction/airway
- 78. George P. Hatzigiannis DMD, MD® Cardiopulmonary Emergencies Respiratory Cardiovascular Laryngospasm Hypertension Bronchospasm Hypotension Asthma Tachycardia Aspiration Bradycardia Apnea Arrhythmia
- 79. Patient under sedation becomes apneic & hypoxic. What airway management tools are there? George P. Hatzigiannis DMD, MD®
- 80. George P. Hatzigiannis DMD, MD®
- 81. George P. Hatzigiannis DMD, MD® First Line
- 82. George P. Hatzigiannis DMD, MD® Laryngeal Mask Airway Improvement to traditional face mask Minimal trauma Semi-secure airway Ease of insertion
- 83. George P. Hatzigiannis DMD, MD® Endotracheal Tube Advantages Disadvantages Most secure airway once placed Placing foreign body through vocal cords Low airway skills after placement Considerable skill to place Seals trachea from GI tract Muscle relaxant to place High airway pressures possible Pulmonary edema
- 84. George P. Hatzigiannis DMD, MD® Cricothyrotomy Palpate cricothyroid membrane Skin incision over membrane Insert scalpel handle, rotate 90° Insert endotracheal tube / trach tube Inflate cuff, ventilate
- 85. George P. Hatzigiannis DMD, MD® Summary Great tool for patient management / comfort One of few things we do that can KILL a patient Provider should be VERY overtrained for degree of sedation provided A weekend course or basic certificate does not replace years of formal training for IV sedation
- 86. George P. Hatzigiannis DMD, MD®
- 87. Thank You! George P. Hatzigiannis DMD, MD®