Conscious sedation is a type of sedation that minimizes pain and discomfort through sedatives and analgesics while maintaining an altered state of consciousness. It allows for quick recovery and is safe and effective for minor procedures. The American Society of Anesthesiologists provides guidelines for four levels of sedation. Common medications used include midazolam, fentanyl, and propofol which are carefully titrated based on the individual patient. Close monitoring of vital signs is required during and after a procedure, and complications like respiratory depression require reversal agents such as naloxone or flumazenil.

1. Conscious sedation
Natangwe T Shimhanda
16/04/2019

2. Primun non nocere

3. What is Conscious
Sedation?
• A type of sedation that “ induces an altered
state of consciousness that minimizes pain and
discomfort through the use of pain relievers
and sedatives.”
• Sedation is a continuum and a patient can
easily fall into a deeper level of sedation

4. Why use Conscious
Sedation?
• Safe and effective for patients who need
minor surgery or diagnostic/interventional
procedures
• Allows for quick recovery

5. Sedation Classes
• American Society of Anesthesiologists (ASA) is
responsible for developing practice guidelines
for procedural sedation
• Four sedation depths classified

6. Continuum of Depth of Sedation

7. Indications of Conscious sedation
• Prolonged or traumatic dental procedures
• Medical conditions potentially aggravated by stress
• Medical conditions affecting the patient’s ability to
cooperate
• Patient lacking cooperation because of lack of
psychological or emotional maturity

8. Contraindications
• Chronic obstructive pulmonary disease (COPD),
epilepsy, & bleeding disorders.
• Uncooperative or unwilling patients.
• Unaccompanied patients..
• Prolonged surgery.
• Lack of equipment or inadequate personnel.

9. Pre-requisites
• Knowledge of the agents to be used
• Informed Consent
• Appropriate equipment required
• Planned rationale for use of sedation

10. Equipment needed
• Oxygen
• Suction
• Ambu-bags adult & pediatric
• Airways all sizes
• Laryngoscope – all size blades
• Endotracheal tubes
• Crash cart with AED
• Sedation medications
• Reversal agents
• Monitoring devices
– Pulse oximeter
– Non-invasive blood pressure
– ECG monitor
– End-tidal CO2 monitor

11. Medications used for Sedation
• Midazolam
• Fentanyl
• Pethidine
• Propofol
• Ketamine
• Thiopentone
Reversal agents:
– Flumazenil (benzodiazepin reverasal)
– Naloxone (opiate reversal)

12. Medications
• Typically, sedatives are used in conjunction
with analgesics (pain relievers) for conscious
sedation
• This combination can have a synergistic effect,
a result greater than the sum of the individual
medications.
• Dosage is titrated for desired effect in each
patient

13. Medications
• Sedatives (initial dosage in parentheses):
• Valium (Benzodiazepine)
– Given PO (5-10 mg) and/or IV (5 mg)
• Midazolam (Benzodiazepine)
– Given IV (1-2 mg)

14. Medications
• Analgesics:
– Fentanyl (Narcotic)
• Given IV (12.5 – 25 mcg)
• Morphine (opiate)- less common
– Given IV (2 – 4 mg)

15. Medications
Hypnotics, typically given only by
anesthesiologist/CRNA:
• Propofol (hypnotic)
– Given IV using weight-based dosing
• Etomidate (hypnotic)
– Given IV using weight-based dosing
Usually given in combination with sedatives

16. CAUTION
• Dosages need to be adjusted for elderly
patients and pediatric patients.
• Regular dosing may cause severe side effects
and complications.

17. Sedation techniques
• Inhalation sedation
• Oral sedation
• Intramuscular sedation
• Intravenous sedation
• Rectal sedation
• Submucosal sedation

18. Inhalation

19. Oral

20. Intravenous

21. Patient Factors Affecting
Response to Sedation

22. Pre-op assessment
• Obtaining patient history & information.
• Age, weight, height
• Health history
• Systems review
• Airway evaluation
• ASA Physical Status Classification
• Adequate documentation of the sedation
experience with monitoring of vital signs

23. During procedure
• Patient must be monitored closely!
– EKG, Heart rate, BP, Oxygen saturation, Airway,
Respiratory rate, Response to stimuli, Appearance
of patient
• Vital signs taken every 5 minutes at minimum

24. Complications
• Respiratory depression
• Respiratory arrest
• Hypotension

25. Reversal/rescue
• “Rescue of a patient from a deeper level of
sedation than intended; correction of adverse
physiologic consequences of the deeper-than
intended level of sedation (such as
hypoventilation, hypoxia and hypotension)
and returns the patient to the originally
intended level of sedation.”

26. Reversal agents
• Medications are available to counteract the
effects of conscious sedation drugs:
– Naloxone- used for narcotic reversal
– Flumazenil- used for benzodiazepine reversal
• Careful monitoring of patient is required
duration of action is less than narcotics and
benzos

27. Post-op
• Patient will be closely monitored 30 minutes
to 2 hours after procedure.
• Depending on type of procedure and amount
of each individual patient’s recovery time,
discharge can be as soon as one to two hours
• Patient should not drive, operate heavy
machinery, or make any legal decisions for 24
hours.

28. References
• Conscious sedation, AMERICAN DENTAL ASSOCIATION,1993
• Shobha Tandon, 2012. TEXTBOOK OF PEDODONTICS; 2nd
edition
• DENTISTRY FOR THE CHILD & ADOLESCENT; 9th edition; R E
McDonald, D R Avery, J A Dean.