Conscious sedation in dentistry,presented to a meeting of Euroscicon at Moscow,Oct.2018,shortened.This is the full version

1. Conscious sedation for dentistry
Claudio Melloni
Anesthesiologist
Private practitioner,Bologna,Italy

2. Conflict of interest
• None;I am a private practitioner,no
sponsors,no links with firms,industries etc...

3. Career
• Spec in anesthesia and ICU 1976
• Spec in Appled Pharmacology 1980
• Posts held Italy :Trieste Maggiore University Hospital 1973-74;Bologna S,Orsola University Hospital
1974-1995
• Director and Head of Anesthesia and ICU Lugo and Faenza Hospitals 1995-2006
• Contract Professor in Anesthesia Unibo 1989-1995
• Private practice from 2006:.Villa Torri,Villa Chiara(inpatients ,maxillofacial
surgery,otyhopedics):,day surgery for plastic surgery , dental ,opthtalmic offices.
• Residency St lukes hospital NYC,USA,. 1976-77
• Fellowship Mc Gill University Montreal,Canada 1980-81
clinical attachments:Oxford,Liverpool,London,Norwich
Experience in all fields of Anesthesia,except neurosurgery.Invasive pain theray for cancer and arterial
occlusive diseases

4. Publications
• Many: British Journal of Anesthesia(1),Canadian Anesth.J.(1),Acta Anesthesiologica
Scandinavica(1) Current Opinion in Anesthesiology (1),Anesthesiology (2) ,Minerva
Anestesiologica many
• Chapter in books and dictionaries on obstetric analgesia/anesthesia,sedation and
anesthesia for day surgery,difficult intubations,propofol,muscle relaxants
monitoring,pain therapy ,lytic blocks.spinal and epidural anesthesia.....
• 90 lectures at italian courses and congresses;SIA(Napoli),SIIARTI,Smart
Milano,many of them available on www : slideshare , researchgate,academia.
• “Anesthesia outside the operating room department:how to decrease risk and
maintain quality.”Curr Opin Anesthesiology,2007 ,num 20,december pagg 513-519
• “Perioperative Risk assessment:an anesthesiologist perspective for
• undergoing noncardiac surgery”,pagg 1-53 .Book:”Risk Management”,ed
Jordao,B,Sousa,E,.Nova Science Publishers,New York,2010.
• La sedazione cosciente in odontostomatologia,booklet 2018 EBS print,isbn.. 978-
88-9349-301-7,april 2018.,206 pagg.

5. Bottom line
All conscious sedation areas(OR,Office....)
Must have:
• Processes:preop. assessment,intraop. monitoring,discharge criteria...)
• Facilities
• Equipment
• Personnel
Similar to those utilized by MAC delivered by
qualified anesthesia providers in the OR

6. Guidelines:
ASA
American Society of Anesthesiologists
Guidelines for office based anesthesia (committee of origin:Ambulatory surgical care:Approved by
the ASA House of Delegates on Oct 13,1999 and last affirmed Oct 21,2009.
BASIC STANDARDS FOR PREANESTHESIA CARE
• Committee of Origin: Standards and Practice Parameters
• (Approved by the ASA House of Delegates on October 14, 1987, and last affirmed on October 28, 2015.
•
STANDARDS FOR BASIC ANESTHETIC MONITORING
• Committee of Origin: Standards and Practice Parameters
• (Approved by the ASA House of Delegates on October 21, 1986, last amended on October 20, 2010, and last
affirmed on October 28, 2015.
•
STANDARDS FOR POSTANESTHESIA CARE
• Committee of Origin: Standards and Practice Parameters
• (Approved by the ASA House of Delegates on October 27, 2004, and last amended on October 15, 2014.
•
GUIDELINES FOR AMBULATORY ANESTHESIA AND SURGERY .Committee of Origin: Ambulatory Surgical Care
• (Approved by the ASA House of Delegates on October 15, 2003, last amended on October 22, 2008, and
reaffirmed on October 16, 2013.

9. Emergency Resuscitative
Equipment

10. Emergency Equipment
• Oxygen – system can deliver 100% at 10 LPM
• Suction – can produce negative pressure of 150 torr
• Airway management
– Face masks (all sizes)
– Oral & nasal airways
– LMAs (laringeal mask airway)
– Endotracheal tubes
– Laryngoscopes

14. COPA

17. Indications for sedation in dentistry:
• dental anxiety and phobia;
• prolonged or traumatic dental procedures;
• medical conditions potentially aggravated
by stress;
• medical conditions affecting the patient’s
ability to cooperate;
• special needs.
• Patient or surgeon preference….

18. Definition of CS
• A technique in which the use of a drug or drugs
produces a state of depression of the central nervous
system enabling treatment to be carried out, but
during which verbal contact with the patient is
maintained throughout the period of sedation. The
drugs and techniques used to provide conscious
sedation for dental treatment should carry a margin of
safety wide enough to render loss of consciousness
unlikely.
• Conscious Sedation: A depression of the patient’s
level of consciousness such that the patient responds
appropriately to physical and verbal commands and
maintains airway protective reflexes

19. Scottish Intercollegiate Guidelines Network (SIGN)
Safe sedation of children undergoing diagnostic and therapeutic procedures. A
national clinical guideline. Scottish Intercollegiate Guidelines Network. February
2002
• extends the definition by
• including no interventions are required to
maintain a patent airway, spontaneous
ventilation is adequate and cardiovascular
function usually maintained

20. Continuum of Depth of Sedation
Definition of General Anesthesia and Levels of Sedation /
Analgesia
(Developed by the American Society of Anesthesiologists)
(Approved by ASA House of Delegates on October 13, 1999)
amended on 27 october 2004
Minimal
Sedation
(“Anxiolysis”)
Moderate
Sedation /
Analgesia
(“Conscious
Sedation”)
Deep Sedation /
Analgesia
General Anesthesia
Responsiveness Normal
response to
verbal
stimulation
Purposeful*
response to verbal
or tactile
stimulation
Purposeful*
response following
repeated or painful
stimulation
Unarousable, even
with painful
stimulus
Airway Unaffected No intervention
required
Intervention may be
required
Intervention often
required
Spontaneous
Ventilation
Unaffected Adequate May be inadequate Frequently
inadequate
Cardiovascular
Function
Unaffected Usually
maintained
Usually maintained May be impaired
* Reflex withdrawal from a painful stimulus is NOT considered a purposeful response
Useful Spectrum

21. Difference between CS and GA
• It is important that a wide margin of safety It is
important that a wide margin of safety between
coConscious/ unconscious state
In conscious sedation, verbal contact
and protective reflexes are maintained,
whereas in general anesthesia these
are lost.

22. Conscious sedation
Moderate sedation
Deep sedation:GA
Continuum of
sedation
Individual response
to sedation
Ability to rescue

23. SEDATION EVALUATION:SCALES

24. Ramsey Sedation Scale
• Response to command score
• Patient awake,anxious ,agitated,restless 1
• Pt. Awake,cooperative,orientated,tranquil 2
• Pt drowsy with response to command 3
• Pt asleep with brisk response to glabella tap or
loud auditory stimulus 4
• Pt asleep,sluggish response to stimulus 5
• No response to firm nail bed pressure or other
noxious stimuli 6

25. OAA/S Observer’s assessment of
awareness/ sedation scale
•
•
Responsiveness speech score
Respons rapidly to name in normal tone normal 5
Lethargic response to name spoken loudly
repeatedly
Mild slowing 4
Responds only after name spoken loudly or
repeatedly
Slurring or slowing 3
Responds after mild prodding or shaking Few recognized words 3
Does not respond after mild prodding or shaking 1

26. UMSS University of Michigan sedation
scale
Sedation score
Awake and alert 0
Minimum
sedation
Tired/sleepy,appropriate response to verbal conversation
or sound
1
Moderate
sedation
somnolent/sleeping,easily arousable with light tactile
stimulation or a simple verbal command
2
Deep sedation Deep sleep,arousable only with significant physical
stimulation
3
unarousable 4

27. From the General Dental Council UK:
• CONSCIOUS SEDATION
• 4.11 Conscious sedation can be an effective method of facilitating dental
treatment and is normally used in conjunction with appropriate
local anaesthesia.
• Conscious sedation is defined as:
• A technique in which the use of a drug or drugs produces a state of
depression of the central nervous system enabling treatment to be carried
out, but during which verbal contact with the patient is maintained
throughout the period of sedation. The drugs and techniques used to
provide conscious sedation for dental treatment should carry a margin of
safety wide enough to render loss of consciousness unlikely.
• The level of sedation must be such that the patient remains
conscious,retains protective reflexes, and is able to understand and to
respond to verbal commands. ‘Deep sedation’ in which these criteria are not
fulfilled must be regarded as general anaesthesia.
• In the case of patients who are unable to respond to verbal contact even
when fully conscious the normal method of communicating with them must
be maintained.

28. PREOP ASSESSMENT

29. Physical Status
Classifications:ASA

30. Classifications:
www.asahq.org/clinical/physicalstatus.htm. accessed april 2007
• ASA 1 ---Normally healthy patient without medical
problems
• ASA 2 --- Mild well controlled systemic disease --- no
functional limitation
• ASA 3 --- Severe systemic disease that results in
functional limitation but non incapacitating
• ASA 4 --- Severe systemic disease that is a constant
threat to life
• ASA 5 --- Moribund patient not expected to survive
regardless of operation
• ASA 6 --- A declared dead patient whose organs are
being removed for donation

31. Estimated Energy Requirements for Various Activities

32. NYHA
Class Patient Symptoms
I No limitation of physical activity. Ordinary physical activity does not cause undue fatigue,
palpitation, dyspnea (shortness of breath).
II Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results
in fatigue, palpitation, dyspnea (shortness of breath).
III Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity
causes fatigue, palpitation, or dyspnea.
IV Unable to carry on any physical activity without discomfort. Symptoms of heart failure at
rest. If any physical activity is undertaken, discomfort increases.

33. Risk Prediction in surgery: Risk Models
• ACPGBI CRC Model
• ACPGBI MLBO Model
• ACPGBI Node Harvesting Model
• St Mark's Node Positivity Model
• Cleveland Clinic Lap Conversion Model
• Cleveland Clinic Pouch Failure Model
• CR-POSSUM
• P-POSSUM
• O-POSSUM
• Vascular-POSSUM Models
• Length of Stay Model
• Nottingham Hip Fracture Score
• ACS NSQIP Surgical Risk Calculator. 2007 - 2017, American College of Surgeons National Surgical Quality
Improvement Program. riskcalculator.facs.org.
– This surgical risk calculator requires to state age,functional status(dependent/independent),emergency yes/no,ASA
PS class,stroid use,vetilator dependency,disseminated cancer,sepsis,diabetes,acute renal insufficiency,hypertension
under treatment,smoke,COPDmdyialysis,BMI(Body mass index)
• Surgical Outcome Risk Tool (SORT) - SOuRCe / NCEPOD
• www.sortsurgery.com
•
• Barnett S1, Moonesinghe SR.
• .Clinical risk scores to guide perioperative management. Postgrad Med J. 2011 Aug;87(1030):535-41. doi:
10.1136/pgmj.2010.107169. Epub 2011 Jan 21
•

37. “At Risk” Patients for Sedation or Analgesia
• The ASA physical status risk classification of 3 or greater
• Critical care patients
• Extremes in age (<1 or >70 years of age)
• Patients with chronic respiratory disease, chronic obstructive
pulmonary disease, emphysema,CHF,CKD,angina…..
• History of sleep apnea
• Mentally and neurologically handicapped patients
• Patients at risk for aspiration (i.e. hiatal hernia with
regurgitation, diabetes with gastroparesis)
• Altered mental status

38. Relative Contraindications

39. Contraindications
• Physical Examination
– Respiratory distress (wheezing, stridor, etc.)
– Hypotension
– Morbid obesity
– OSA?????
–Craniofacial abnormalities
• Short neck
• Decreased hyoid-mental distance (<3cm in adult)
• (Distorted landmarks on anterior surface of neck)
• Limited mouth opening
• Receding chin
• Large tongue
• Unable to view base of uvula with mouth open and tongue
protruding

40. Pregnancy
• Patients who are trying to conceive, are
pregnant or are breast-feeding must inform
their dentist in advance of their appointment.

41. Mallampati Classification
• Class 1: Full visibility of tonsils, uvula and soft palate
• Class 2: Visibility of hard and soft palate, upper portion of tonsils and uvula
• Class 3: Soft and hard palate and base of the uvula are visible
• Class 4: Only hard palate is visible
The Mallampati classification is used to
predict the ease of intubation. It is
determined by looking at the anatomy of
the oral cavity. Specifically, it is based
on the visibility of the base of uvula,
faucial pillars and soft palate. Scoring
may be done with or without phonation.
A high Mallampati score (class 3 or 4) is
associated with more difficult intubation
as well as a higher incidence of sleep
apnea.

42. OSA screening

43. clinical diagnosis of OSA
• The clinical diagnosis of OSA was defined as
AHI(apnea /hypopnea) greater than 5
with fragmented sleep and daytime
sleepiness.
• According to the American Academy of Sleep
Medicine practice guideline, the severity of
OSA is determined by the AHI: 5–15, mild;
greater than 15–30, moderate; greater than
30, severe.

44. S.T.O.P.:snore,tired,observed(s
topped breathing),pressure
STOP Questionnaire.A Tool to Screen
Patients for Obstructive Sleep Apnea
.Anesthesiology 2008; 108:812–21

45. Pre sedation assessment
• A fully recorded medical history;excerpt from GP????mail
questionnaire ?FAX?
– A dental history.
– Comorbidites
– Medications
– Allergies
– A conscious sedation and general anaesthetic history.
To be reviewed immediately before procedure!
• FOCUSED Assessment
• Blood pressure.
• Age,Weight, height
• ASA status.
• Physical activity
• MET equivalents

46. Assessment and Planning
• Dental treatment plan.
• The selected conscious sedation technique.
• Any individual patient requirements.
• Provision of pre- and post-operative written
instructions before treatment.
• Written consent for conscious sedation and
dental treatment.

47. Goals of Sedation
• To titrate the medication such that the
smallest amount of medication is
administered to achieve the desired
depression of consciousness while
minimizing potential complications.
– Desired Effects:
• Depressed consciousness
• Amnestic of procedure
• Minimal variation of vital signs
• Compliance with surgery!

48. Complications
• Deep unarousable sleep
• Hypotension
• Bradycardia
• Agitation and combativeness
• Hypoventilation
• Respiratory depression
• Airway obstruction
• Apnea

49. Sedation is an art....
sedation
Dentist
Experience
Skills
Relationships...
Office
Anesthesiologist
Pharmacology
Experience
Skills
Relationships... Patient
Psychology
Physiology
Diseases
Drugs....

50. Max mouth opening,mouth
prop,rubber dam,etc
• Reduce the retropalatal and retroglossal areas,
lengthening of the pharynx and shortening of the
MP-H,dyspnea + and SaO2
• Hiroshi Ito,Hiroyoshi Kawaai,Shinya Yamazaki,Yosuke Suzuki.Maximum opening of the mouth by mouth propduring
dental procedures increases the risk
of upper airway constriction.Therapeutics and Clinical Risk Management 2010:6 239–
• increases UA collapsibility during sleep
• J C Meurice,Isabelle Marc,CG arrier,F SérièsEffects of mouth opening on airway collapsibility in normal
sleep subjects.American Journal of Respiratory and Critical Care Medicine 1996;153(1):255-9
.
• decrease upper airway patency and disrupt
breathing pattern.
• Iwatani K, Matsuo K, Kawase S, Wakimoto N, Taguchi A, Ogasawara T.
• Effects of open mouth and rubber dam on upper airway patency and breathing.
Clin Oral Investig. 2013 Jun;17(5):1295-9.

53. Maximum opening of the
mouth by mouth prop
during dental procedures
increases the risk
of upper airway constriction
Hiroshi Ito,Hiroyoshi Kawaai,Shinya Yamazaki,Yosuke Suzuki.Maximum opening of
the mouth by mouth prop during dental procedures increases the riskof upper
airway constriction.Therapeutics and Clinical Risk Management 2010:6 239–2

54. Airway
difference
between
closed and
fully open
mouth

55. Cases from personal experience
• See following slides…. • C.M.,64,kg 100,cm 180,walks a
lot,hunting(hills…);appendectomy
and hernia repir in the past
• Lab:BAV 1,BP 140/105….creat 2,06…
• Physical;strong man
• However:Mi 3years before + TIA
without sequelae
• Medications:cardicor,cardioasp,lasix,
novonorm,Lescol,senikar,zyloric
• Intraop(7 hrs,uneventful,sinus
elevation,multiple implants upper
and lower.)
• the day after working in the garden…
• 2 days later:stroke!

56. Rino M.,paz di dott.MV
• Teeth abscess!
• Male,white, 88 years, 74kg,cm 178
• ASA 4 ;Met 2
• EF 25% ;CHF,PM, AAA,IRC ,low platelets
• Drugs: …………………….
• Premed:midaz4;surgery after 25 min,midaz
0,5+fent 40 microgr ;2 episodes SaO2 <90%;O2
given 1 lt/min.Otherwise stable(BP 108/65),
• Surgery duration:50 min.

57. Rosa V-paz dott G”J”P.
• female 70 y, 60 kg, 160 cm,
• ASA 4 (cardiomiop dilat ,diabetes)
• Anesth stand by with monitoring only!!!
• Vital signs stable.,BP 149 /73
• Surg.dur:90 min.

58. R- T.,paz dott PP
• 87 yrs,50 kg,155 cm.
• Alzheimer
• Multiple teeth extraction;25 min.
• Midaz 3 mg
• Vital signs stable.

59. V V,paz di FP
• Multiple implants
• Male,76 y,79 kg,cm 174
• ASA 4;cardiomyopath dilat,(but FE improved to
50%),COPD,chronic gastritis.
• Drugs:Bisoprolol,valsartan 40,atorvastatin
,furosemide,lansoprazol venlafaxin,clonazepam
• Premed:triazolam 0.5 mg,30’ before
• Induct;midaz 1,no fent
• Surg dur:115 min
• Vital signs stable,no problems

60. Alvise Z.,92b a,kg 80,cm 160(DR. MV.)
• Very bright,retired adm. of major companies.
• CHF,,COPD,MI 2016,angio, 2 stent
• Dic 2015 e.coli sepsis with distented cholcec. And reflex ileus
• BP 110-60,ekg sinus bray+ MI signs
• ASA 4?
• Drugs:ivrabradina,furosemide,zofrenopril (ace inib), +spironolattone
,statins,cardioasp. Bronchodila,salmeterol + fluticasone,tiotropio(antg
muscarine not selective)
• However cyclette 20 min*2 /die, walks 2 blocks
• Premed:diaz 4 mg p .os 25 min before :
• Induct: midaz 0.5 mg iv:Ramsey 2-3.
• BP,HR,SaO2,etco2 ok:O2 1 lt/min
• 2 implants,50 min.
• OK OK ,home walking with servant.

62. Sedation protocol for higher risk
patient…valid for all???
• Recognize the patient medical risk
• Complete medical consultation before dental treatm.;GP?Specialist?
• Schedule pt’ appointment at a time of day when their stress will be less
• Arrange the appointment during the first days of the week when the office
is open for emergency care and the treating doctor/specialist is available.
• Monitor and record preop,intraop,.postop vital signs.
• Use sedation regimen with minimal potential for physiologic disturbances
• Administer adequate pain control during and after treatment
• Ensure length of appointment does not exceed pt’s limits of tolerance
• Follow up postop pain and anxiety control
• Telephone later in the same day/night for control
• Telephone the following day

63. PERSONAL EXPERIENCE

65. Adverse effects :percentage
0
5
10
15
20
25
30
35
40
bradycardia hypercapnia hypertension hypotension desaturation sleep tachycardia
%
clonidine
Effortil,
crystalloids
Oxygen
stimulation
Cause???
atropine

67. Total
midazolam(mg/kg) and fentanyl(microgr/kg) consumption
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
mean SD
midaz
fent

69. Duration of ....
0
20
40
60
80
100
120
140
time to procedure procedure duration hypercapnia duration sleep duration
mean
SD
minutes

70. 0
2
4
6
8
10
12
14
retropalatal distance retroglossal distance mandibular plate-hyoid
mouth closed
mouth open

71. Premed effects on blood pressure
0
20
40
60
80
100
120
140
160
mean DS mean DS
no premed premed
Systolic BP
diastolic BP

72. Summary of Fasting Recommendations to
Reduce the Risk of Pulmonary Aspiration
• Ingested Material
– Clear Liquids – 2 h
– Breast milk – 4 h
– Infant formula – 6 h
– Non-human milk – 6 h
– Light meal – 6 h
Minimum Fasting Period

73. Environment
Patient
selection
Qualifications
training
experience
Safe
practice
Minimum standards
Continuing professional development
Clinical audit
Current
standards
guidelines

74. Monitoring of Patients

75. Monitoring of Patients
• Personnel
– *Nurse or *physician other than the physician
performing the procedure
– Team member able to establish an airway, provide
positive pressure ventilation (Ambu bag)
– Mechanism for additional personnel with
Advanced Life Support capability
– *ACLS required for physicians and nurses

76. Monitoring of Patients (continued)
• Record
– Blood pressure
– Pulse oximetry
– Respiratory rate & depth of respiration

77. Monitoring of Patients (continued)
• Record
– Supplemental oxygen throughout procedure
– Continuous EKG
– Level of consciousness—ask simple questions
– Medications – dose & times

78. •Same standards as
per O.R
•Continuous
anesthetic
surveillance.

79. Requisites
• Any unit providing sedation techniques should have the
following
• readily available :
• Suitably trained individual to monitor the patient
– • ECG
• • Non-invasive blood pressure monitoring
• • Pulse oximetry
• etCO2 …..
• Further requirements include:
• • The patient should be sedated on a trolley or operating table that can
be tipped head-down
• • Oxygen should be readily available
• • Full resuscitation equipment should be available
– Laryngoscope,LMA’s,suction,ventilator,etc...drugs(lipids?)…………..
• • The staff looking after the patient should be trained and regularly
updated in resuscitation techniques.

80. Datex cardiocap NIBP;ECG,SaO2

81. Emergency Equipment (continued)
• Defibrillator with EKG recording capability
• Emergency drug card and ACLS protocols
• Emergency drugs include
– Naloxone (Narcan)
– Flumazenil (Romazicon, Mazicon)
– Ephedrine
– Epinephrine

82. From Minnesota Board of Dentistry 2008
• Practice and equipment requirements.
• A. Dentists who administer general anesthesia or conscious sedation or who
provide dental services to patients under general anesthesia or conscious
sedation must ensure that the practice requirements in subitems (1) to (3)
are followed.
• (1) A dentist who employs or contracts another licensed health care
• professional, such as a dentist, nurse anesthetist, or physician anesthesiologist, with
the qualified training and legal qualification to administer general anesthesia or
conscious sedation must notify the board that these services are being provided in
the office facility.
• The dentist is also responsible for maintaining the appropriate facilities,
equipment,emergency supplies, and a record of all general anesthesia or conscious
sedation procedures performed in the facility.
• (2) An individual qualified to administer general anesthesia or conscious
• sedation, who is in charge of the administration of the anesthesia or sedation, must
remain in the operatory room to continuously monitor the patient once general
anesthesia or conscious sedation is achieved and until all dental services are
completed on the patient.
• Thereafter, an individual qualified to administer anesthesia or sedation must ensure
that the patient is appropriately monitored and discharged as described in subparts 2,
items B and C, and 3, items B and C.
• (3) A DENTIST ADMINISTERING GENERAL ANESTHESIA OR CONSCIOUS SEDATION TO A

83. Equipment recommendations
Minnesota Board of Dentistry 2008
• B. Dentists who administer general anesthesia or conscious sedation or who provide dental services
to patients under general anesthesia or conscious sedation must ensure that the offices in which it is
conducted have the following equipment:
• (1) an automated external defibrillator or full function defibrillator that is
immediately accessible;
• (2) a positive pressure oxygen delivery system and a backup system;
• (3) a functional suctioning device and a backup suction device;
• (4) auxiliary lighting;
• (5) a gas storage facility;
• (6) a recovery area;
• (7) a method to monitor respiratory function; and
• (8) a board-approved emergency cart or kit that must be available and
readily accessible and includes the necessary and appropriate drugs and
equipment to resuscitate a nonbreathing and unconscious patient and
provide continuous support while the patient is transported to a medical
facility.
• There must be documentation that all emergency equipment and drugs are
checked and maintained on a prudent and regularly scheduled basis.

86. OFFICES,IDEAL VS DAILY LIFE

105. Bougie,Forceps,Introducer+O2,LMA,sp
are batteries,lubricant,O2 and CO2
prongs

113. MOVING ALL THESE ITEMS...

115. The last one

117. Medications

118. general characteristics
of drugs for conscious sedation
 a large margin of safety,
Predictable dose response
 painless route of administration
 rapid onset and rapid recovery
Lack of drug accumulation
 easy reversibility
Easy administration
 no/few side-effects.
Minimal adverse interactions with other drugs
Cost effective
Unfortunately ….no drug or combination of drugs completely
achieves all these ideals. The South African Dental Association
GUIDELINES on
CONSCIOUS SEDATION in DENTISTRY
Revised Draft 13th April, 2001

119. titration
• titration of the dose according to the
individual patient’s needs

120. Premedication,p.os
• If time allows (at least 20 min)before operation:
– in case of operation > 120 min
• Triazolam 0.25-0.5 mg or diazepam 0.1 mg/kg up to a max. of
10 mg
• Ibuprofen 400-600 mg (in case of gastritis hx or coagulation
abnormalities,celecoxib 200 mg)
• In case of shorter operation(< 90 min):
• Midazolam 0.08 mg/kg+ Ibuprofen 400-600 mg (in case
gastritis hx or coagulation abnormalities,celecoxib 200 mg )
– Skin topical anesthesia (lidocaine 15% spray) on the
area of the venipuncture

121. dosages
midazolam lorazepam diazepam triazolam
preop 0.5-5 mg 0.5-2 mg 2-10 mg 0.25 mg
Conscious
sedation:
initial dose
0.5-5 mg iv na Na 0.25 mg
maintenance 0.25-2 mg q 15-
80 min
Na Na Na
Induction of
anesth,
0.2-0.35 mg/kg 0.1 mg/kg 0.3-0.5 mg/kg Na

122. Clinical characteristics and
Pharmacodynamics
midazolam lorazepam diazepam triazolam
sedation 2 5 1 1
amnesia 1 4 1 1
hypnosis 1 1 0.5 2
onset 30-60 sec 1-2 min 1 min 30-60 min
Peak effetct 3-.5 min 20-30min 3-4 min 60-120 min
duration 15-80 min 5-6 h 1-6 h 2-6 hr
Triazolam dopo 0,5 mg p os in young healthy males 77 kg overall mean +/- s.e.
mean (with range) kinetic variables were: peak plasma concentration, 4.4 +/-
0.3 (1.7-9.4) ng ml-1; time of peak, 1.3 +/- 0.1 (0.5-4.0) h after dose;
elimination half-life, 2.6 +/- 0.1 (1.1-4.4) h; total AUC: 19.1 +/- 1.1 (4.4-47.7) ng

123. Induction
• Goal;patient calm,relaxed,cooperative,slight
drowsiness,obeying commands.
• Full monitoring;continuous ECG,SaO2,end tidal
CO2(nasal),NIBP(non invasive blood pressure)
every 5 min
• Slow drip i.v(cannula) with normal saline 250 ml
• Midazolam i.v.1-3 mg(2-5 mg in case of no
premed)
• Fentanyl i.v.0.7-0.8 microgr/kg 3 min before
local/troncular done by the surgeon

124. Maintenance
• Midazolam i.v.0.5-1 mg boluses as needed
• Fentanyl i.v .0.025-0.05 microgr/kg as needed
• O2 nasal if SaO2<90% or respiratory
depression

125. Immediately before the end of surgery
• Betamethasone/dexamethasone 2-4 mg i.v.
• If patient complains of pain:paracetamol 1 gr
i.v.
• Ketorolac 30 mg i.v.

126. BDZ administration warnings
• Reduce dosages in elderly pts
• Reduce dosages with other
sedatives/analgesics…
• Titrate!
• Have always flumazenil available

127. Benzodiazepines: short acting
Generic
TRADE
Equiv
alent
Dose/
Class
mg
Peak Level/
ABSORPTION
RATE
hr
Average*
Half-life (hr)
Active
Metabolites
Comments
(V =
therapeutic
use)
INITIAL
MAX DOSE
mg
USUAL DOSE
RANGE
mg
Alprazolam
Xanax,apravecs,a
lprazig,frontal,val
eans
0.5 1-2 h
medium
12
(9-20)
Minor oxidation 0,25
4-10
0.25-0.5
Lorazepam
Contro,lorans,sli
pirem,tavor,zelor
am
1 1-4 p.o
5-10 min iv
15
(8-24)
No
coniugation
0.5
10
0.5-2
Oxazepam
Limbiasl,serpax
15 1-4 8
(3-25)
No
coniugation
10
120
15-30
Temazepam
Euipnos,dormiso
n
10 2-3 11
(3-25)
No
coniuigation
15
60
15-30
Triazolam
halcion
0,25 1-2 2
(1.5-5)
No
oxidation
0,125-0.5 0.125-0.25
Long
acting
Diazepam
Ansiolin,noan,tra
nquirit,valium,va
5 1-2
8 iv
diazemuls
100 Yes
oxidation
2
20
2-5

128. Triazolam dosage:p.os,30-45 min
before
age
weight <60 60-70 70-80
50 0.25 0.25 0.125
60 0.375 0.25 0.25
70 0.5 0.375 0.25
80 0.5 0.5 0.25
90 0.5 0.5 0.25

129. Midazolam dosage;i.v.,for induction of
sedation
age
weight <60 60-70 70-80 >80
50 2 2 1 0.5
60 2 2 1 0.5
70 3 2.5 2 0.5
80 4 3 2 1
90 4 2.5 1 1
Dilute 1 fl (1 ml,5 mg ) with 4 ml saline:=1 mg/ml
Do not stock other preparations of midazolam( 15
mg/ml)!!!

130. Dosage: BDZ
• Dosage diazepam : P.Os:Valium2;gtt 1ml= 5 mg 10 gtt=2 mg
• Dosage: 0.5 gt/kg, 1 gtt/2 kg
• 40 kg=20 gtt
• 50 kg=25 gtt
• 60 kg=30 gtt
• 70 kg=35 gtt
• 80 kg=40 gtt
• 90 kg=45 gtt
•
• :I.m or i.v
• Diazemuls;fl,2 ml,5mg/ml
• Dosage :0.1 mg/10 kg
• 40 kg=0.8 ml
• 50 kg=1 ml
• 60 kg=1.2
• 70 kg=1.4 ml
• 80 kg=1.6 ml
• 90 kg=1.8-2 ml

131. Triazolam(Halcion),p.os,30-45 min
before

132. Midazolam(Ipnovel) ev,mg
Età anni
Peso kg <60 60-70 70-80 >80
50 2 2 1 0.5
60 2 2 1 0.5
70 3 2.5 2 0.5
80 4 3 2 1
90 4 2.5 1 1

133. BDZ suggestions
• Reduce dose :
– with elderly or frail pts
– With other sedatives/analgesiscs(potentiation....)
– itolare la somministrazione in relazione agli effetti
desiderati(RAMsey 3,massimo 4)
• Titrate to effect (wait...)
• Have always flumazenil available
• Do not inject diazepam through peripheral veins ;in
case use Diazemuls
• Beware od side effects and paradoxical too
• With fast injection beware of respiratory depression

134. Other powerful sedatives
drug Induction Maintenance Side effects Suggestions
Propofol(Dipriva
n)**
0-2-0.5 mg/kg
ev
1-3 mg/kg/g Hypotension
resp.depress.
+ lidoc
inject.pain.
Dexmedetomidi
ne(Precedex)
0.5-1 microgr/kg
+ 10 minnev
0.2-0.5
microgr/kg/h
hypotension
bradycardia
Risveglio
prolungato
Haloperidol(Sere
nase)**,droperi
dol
1-2 mg ev o im NO extrapiramid.rigi
d.
In case of severe
agitation...
Phenotiazine(Pr
omazine=Talofe
n,Chlorpromazin
e=Largactil ,**
25-50 mg ev ,
im.,os
NO distonic
reactions,
Tachycardia,hyp
otension ;be
aware of
environm. temp.
!!!
In case of severe
agitation......
**:poweful
antiemetics

135. NITROUS OXIDE :N2O

139. N2O;proprieties
• Good analgesia
• Individual threshold
• No cardiovascular effects
• No resp.depression
• Fast on/fast off
• Beware pollution!!!
– Teratogenic?
– B12 anemia
– Potentiation with other sedatives/analgesics
– Contraindications(pnx,bullae,otitis ...)

140. ANALGESICS

141. Opioids
Drug Dose recomm.
E3v(Bolus)
Peak
effect(min
)
Durati
on
(min)
reccomendaations
meperidine(Demerol) 10-30 mg 10-20 60-120 Slow injection.Active metabolites.Negative
inotropic
Top up dosages::10-20 mg. Tachycardia
fentanyl (Fentanest) 0.5-1 microgr/kg 3-5 30-60 Top up dosages::10-20 microgr
remifentanil(ultiva) 10 -20 microgr 1 5-10 Continuous infusion,low dise 1-2
microg/kg/h
Alfentanil(Fentalim) 10-20 microgr/kg 2-3 20-40 Top up doses :1-.5 microgr/kg

142. POSTOP.ANALGESIA

144. Drugs organized by action
hypnotics,sedative analgesics emergenzy
Diazepam fentanyl ondansetron
triazolam paracetamol dexamethasone
Midazolam codeine adrenaline
propofol tramadol atropine
ketamine Ketorolac
l
amiodarone
dexmedetomidine celecoxib lidocaine
clonidine
naloxone
flumazenil
ephedrine
chlorpheniramine
salbutamol

145. Drugs organized by timing
premed intraop postop
Codeine+paracetamol midazolam Antidotes;flumazenil,naloxon
triazolam fentanyl Vs
PONV:ondansetron,dexamet
hasone
midazolam Propofol Analgesics;celecoxib,codeine
+paracetamol,paracetamol,k
etorolac,tramadol(???)
diazepam Dex???
Antibiotics ; a
couple:amox,genta,cilinda,ci
proflox…..
Ket????
Halop or drop Cristalloids;NACl,PET
Colloids:HES

146. Vital signs monitor(s)
• General principles:
– Robust,but protect during transport ,good packaging
– Lightweight;???< 1kg…..
– Battery operated ;look for replacement
– Easy to operate
– Good visibility
– Good price
– Maintenance free,parts easy to find(cables,sensors)
• ECG,NIBP,SaO2,EtCO2,resp.
• EEG?????CSM…..
• Spare monitoring in case of failure;at least SaO2…
• Thermometer
• Phonendoscope

147. Emergency material
• Laryngoscope;2 at least,check batterie frequently
• Full assortment of blades,right and curves
• LMA size 2,3,4,5
• Bougie
• Magill forceps,
• Frova introducer
• O2 and CO2 catheters
• IV lines(latex free)+ three way extension
• Defibrillator,portable,battery operated,semiautomatic
• tracheostomy kit????
• Hand or foot operated suction
• Self inflating bag+reservoir(O2 100% capable)
• Face masks
• Guedel airway,any size(COPA)
• Oxygen tank;5 lt??3 lt?2 lt? 1 lt?

148. Practice Guiding priciples
• Never trust anyone
• Never run out on anything;replace immediately
• Always have more you think you migh need
• Pack everything by yourself so you know what
you have and where it is to be found
• Assume the practice has nothing except suction
and light(but you may inquire beforehand…)

149. Items for comfort
• Your own surgical clothes
• Patient blanket????

150. REFERENCE DOCUMENTS from UK Standards for Conscious Sedation in Dentistry:
Alternative Techniques 2007
1. Conscious sedation in the provision of dental care. Report of an Expert Group on Sedation for
Dentistry. Standing Dental Advisory Committee (SDAC) 2003.
http://www.advisorybodies.doh.gov.uk/sdac/conscious_sedationdec03.pdf
2. Implementing ensuring safe sedation practice for healthcare procedures in adults. Academy of
Medical Royal Colleges. November 2001
http://www.rcoa.ac.uk/docs/safesedationpractice.pdf
3. Conscious sedation in dentistry. Practice inspection check list. Basic sedation techniques. Society
for the Advancement of Anaesthesia (SAAD) 2004
http://www.saaduk.org/docs/practice_inspection_checklist.pdf
4. Conscious sedation in dentistry. PCT Practice inspection check list. Notes for users. SAAD. 2004
http://www.saaduk.org/docs/practice_inspection_checklist_notes.pdf
5. Conscious Sedation: A Referral Guide for Dental Practitioners. Dental Sedation Teachers’ Group in
liaison with SAAD. 2001
http://www.dstg.co.uk/teaching/conc-sed/
6. CDO Update. Department of Health. January 2005
http://www.dh.gov.uk
7. Training in Conscious Sedation for Dentistry. Dental Sedation Teachers’ Group. August 2005
http://www.dstg.co.uk/
8. The First Five Years. General Dental Council. August 2002
http://www.gdc-uk.org
9. Health Economic Evaluations Database. Office of Health Economics.

151. Biblio UK from Standards for Conscious Sedation in Dentistry:
Alternative Techniques 2007
• 10. Conscious Sedation in Dentistry. Dental Clinical Guidance. National Dental Advisory
• Committee. Scottish Dental Clinical Effectiveness Programme. May 2006
• 11. Commissioning Conscious Sedation Services in Primary Dental Care. Department of Health.
• June 2007 [Gateway Reference 8338]
• 31
• 12. Averley PA, Girdler NM, Bond S, Steen N, Steele J. A randomised controlled trial of paediatric
• conscious sedation for dental treatment using intravenous midazolam combined with inhaled
• nitrous oxide or nitrous oxide/sevoflurane. Anaesthesia (2004) 59: 844-852
• 13. Dionne RA, Yagiela JA, Moore PA, Gonty A, Zuniga J, Beirne OR. Comparing efficacy and
• safety of four intravenous sedation regimens in dental outpatients. Journal of the American Dental
• Association (2001) 132: 740-751
• 14. Ganzberg S, Pape RA, Beck FM. Remifentanil for use during conscious sedation in outpatient
• oral surgery. Journal of Oral and Maxillofacial Surgery (2002) 60: 244-250
• 15. Sandler NA Hodges J, Sabino M. Assessment of recovery in patients undergoing intravenous
• sedation using bispectral analysis. Journal of Oral and Maxillofacial Surgery (2001) 59: 603-611
• 16. Burns R, McCrae AF, Tiplady B. A comparison of target controlled therapy with patient
• controlled administration of propofol combined with midazolam for sedation during dental surgery.
• Anaesthesia (2003) 58: 170-176
• 17.. Leitch JA, Anderson K, Gambhir
• S et al. A partially-blinded randomised controlled trial of
• patient-maintained propofol sedation and operator controlled midazolam sedation in third molar
• extractions. Anaesthesia (2004) 59: 853-860
• 18. Conscious sedation in termination of pregnancy: Report of the Department of Health Expert
• Group. London: Department of Health, 2002

153. Effects of premed on basal systolic pressure

154. Effects of premed on basal diastolic pressure