Concious sedation

contents
 Introduction
 Historical development of conscious sedation
 Sedation Continuum and related terminologies
 Objectives of conscious sedation
 Harmful Effects
 Philosophy of conscious sedation
 Indication of conscious sedation
 Contraindication of conscious sedation
 Guiding Principles
 Pharmacology of sedative agents
 Routes of drug administration
 Summary and Conclusion
 introduction
“the production of a state of pleasant relaxation & freedom from fear &
anxiety in the conscious patient through the use of drugs.”
- American Society Of Anaesthesiologists

“a minimally depressed level of consciousness that retains the patient’s

ability to independently & continuously maintain an airway & responds
appropriately to physical stimulation or verbal command & that is
produced by a pharmacological or non-pharmacological method or a
combination thereof”.
- The house of delegates of
- AMERICAN DENTAL ASSOCIATION (ADA)
 HISTORICAL BACKGROUND
 Conscious sedation techniques have been used in dentistry for over 50 years.

 In the USA,
- HORACE WELLS (1844), used nitrous oxide for the first time
- WILLIAM MORTON (Oct, 1846), administered ether for the dental extractions

 In ENGLAND,
- JAMES ROBINSON (Dec, 1846), was the first to administer ether to a patient in
LONDON.

 By the 1904, procaine was available for use in dental patients.

 By the 1930s, an intravenous barbiturate, hexobarbitone, was in use in UK dental

practices for sedation.
YEAR DEVELOPMENT

1940s “Relative Analgesia “ ( nitrous oxide / oxygen )

1960s IV methohexitone (Brietal)

1966 IV diazepam (Valium)

1970s IV diazepam (Diazemuls)

1983 IV midazolam (Hypnovel)

1988 IV flumazenil (Anexate)

1990s IV propofol (Diprivan)

 Sedation Continuum & related
Terminologies
-ASA, 2006, 2007 (revised)

 Minimal Sedation (Anxiolysis)

 Moderate Sedation/ Analgo-sedation/ Conscious Sedation

 Deep Sedation

 General Anesthesia
 Minimal Sedation (Anxiolysis)
a drug-induced state during which children respond normally to verbal
commands. Although cognitive function and coordination may be
impaired, ventilatory and cardiovascular functions are unaffected.

Note: This level is rarely adequate for an infant or young child

undergoing sedation for a procedure.
 Moderate Sedation (formerly Conscious Sedation**)
a drug induced depression of consciousness during which sedatives or
combinations of sedatives and analgesic medications are often
used and may be titrated to effect.

 Children respond purposefully to verbal commands, either alone or

accompanied by light tactile stimulation.

 No interventions are required to maintain a patent airway, and

spontaneous ventilation is adequate. Cardiovascular function is usually
maintained.
 Dissociative Sedation
(Ketamine) A trancelike, state occurs with both profound analgesia
and amnesia while maintaining protective airway reflexes, spontaneous
respirations, and cardiopulmonary stability.

 Child’s eyes remain open with nystagmic gaze; may exhibit random
tonic movements of extremities.

 Causes hyperactive airway reflexes, with a risk of larynogspasm.

 Does not blunt protective airway reflexes to the same degree as other
sedatives (e.g., opioids, benzodiazepines).
 Deep Sedation
a drug-induced depression of consciousness during which patients
cannot be easily aroused, but respond purposefully following repeated
or painful stimulation.

 The ability to independently maintain ventilatory function may be

impaired.
 Patients may require assistance in maintaining a patent airway, and
spontaneous ventilation may be inadequate.
 Cardiovascular function is usually maintained.
 General Anesthesia (GA)
a drug-induced loss of consciousness during which patients are not
arousable, even by painful stimulation.

 The ability to independently maintain ventilatory function is often

impaired.
 Patients often require assistance in maintaining a patent airway, and
positive pressure ventilation may be required because of depressed
spontaneous ventilation or drug-induced depression of neuromuscular
function.
 Cardiovascular function may be impaired.
 OBJECTIVES OF CONCIOUS SEDATION
1) The patient’s mood must be altered…
……so that a procedure becomes readily acceptable.
……to eliminate fear & apprehension & thereby aid in control of pain reaction.

2) The patient must remain cooperative…

3) The pain threshold should be elevated…

4) There should be only minor deviations in the patient’s vital signs…

5) There may be a degree of amnesia…

6) All protective reflexes must remain active…

PHILOSOPHY OF CONCIOUS
SEDATION
INDICATIONs OF CONSCIOUS SEDATION
 Most patients requiring sedation are those with a simple genuine fear or
phobia of dental treatment.

 Patients with mild systemic disorders such as controlled hypertension,

angina, & asthma which may be exacerbated by the stress of dental treatment
represent medical indication.

 Patient with neuromuscular disorders such as spasticity, Parkinsonism &

involuntary movement conditions often wish to cooperate but physically can
not.

 Problems such as gagging & trismus, persistent fainting & moderately

difficult or prolonged surgery.
 CONTRA INDIACATIONs OF CONSCIOUS
SEDATION
 Patients with significant cardio respiratory disease or neuromuscular weakness
or wasting conditions.

 Patients with severe psychiatric disorders or mental disability.

 Pregnant patients and lactating mothers.

 Uncooperative, unwilling or unaccompanied patients.

 Sedation should not be attempted if the dental practitioner or his assistants

have insufficient training or experience.
Each sedation should be tailored to the individual child considering
the following factors:
 Joint Commission’s Patient Care
Standards for Sedation and Analgesia,
2008
-Joint Commission Resources: Comprehensive Accreditation Manual for Hospitals:
The Official Handbook. Oakbrook Terrace, IL: Joint Commission on
Accreditation of Healthcare Organizations, 2007, PC41-43.

The rationale and elements of performance for the Patient Care

Standards 13.20 – 13.40.
 Rationale
Because the response to procedures is not always predictable and sedation-to-
anesthesia is a continuum, it is not always possible to predict how an
individual will respond. Therefore, qualified individuals are trained in
professional standards and techniques to manage patients in the case of a
potentially harmful event.
 Elements of Performance
 Sufficient numbers of qualified staff (in addition to the individual performing the
procedure) are present* to evaluate the patient, help with the procedure, provide
sedation and/or anesthesia, monitor and recover the patient.

*For hospitals providing obstetric or emergency operative services, this means

they can provide anesthesia services as required by law and regulation.

 Individuals administering moderate or deep sedation and anesthesia are

qualified and have the appropriate credentials to manage patients at whatever
level of sedation or anesthesia is achieved, either intentionally or
unintentionally.
 A registered nurse supervises perioperative nursing care.

 Appropriate equipment to monitor the patient’s physiologic status is available.

 Appropriate equipment to administer intravenous fluids and drugs, including blood

and blood components, is available as needed.

 Resuscitation capabilities are available.

 The following must occur before the operative and other procedures or the
administration of moderate or deep sedation or anesthesia:

1. The anticipated needs of the patient are assessed to plan for the appropriate level of
postprocedure care.

2. Preprocedural education, treatments, and services are provided according to the plan
for care, treatment, and services.

3. Conduct a “time out” immediately before starting the procedure as described in the
Universal Protocol.

4. A presedation or preanesthesia assessment is conducted.

5. A licensed independent practitioner with appropriate clinical privileges plans or

concurs with the planned anesthesia.

6. The patient is reevaluated immediately before moderate or deep sedation and before
anesthesia induction.
 Appropriate methods are used to continuously monitor oxygenation,
ventilation, and circulation during procedures that may affect the patient’s
physiological status.

 The procedure and/or the administration of moderate or deep sedation or

anesthesia for each patient is documented in the medical record.
 The patient’s status is assessed immediately after the procedure and/or administration
of moderate or deep sedation or anesthesia.

 Each patient’s physiological status, mental status, and pain level are monitored.

 Monitoring is at a level consistent with the potential effect of the procedure and/or
sedation or anesthesia.

 Patients are discharged from recovery/hospital by a qualified licensed independent

practitioner or according to rigorously applied criteria approved by the clinical leaders.

 Patients who have received sedation or anesthesia in the outpatient setting are
discharged in the company of a responsible, designated adult.
PHARMACOLOGY OF SEDATIVE AGENTS
Properties of the ideal sedative drug:

 Comfortable, non-threatening method of administration

 Rapid onset

 Predictable sedative / anxiolytic action

 Controllable duration of action

 Produces analgesia

 No side effects

 Rapid and complete recovery

 INHALATIONAL AGENTS

•Commonly used for dental sedation.

•No currently available agent is ideal.
•The greatest potential danger when using inhalational
sedation is the failure to deliver an adequate supply of
oxygen to the patient, due to inappropriate or faulty
equipment.
Properties of an ideal inhalational sedation agent:

Induction characteristics Smooth

Anxiolysis Yes
Cardio respiratory stability Stable
Ease of titration Easy
Induction & recovery rate Rapid
Metabolism 0%
Ease of breathing Non – pungent
Blood gas solubility Low
Potency (MAC) Weak (high)
Speed of change in sedation level Rapid
Systemic toxicity None
Environmental effects None
Analgesia Yes
 NITROUS OXIDE
 It is colorless & inorganic agent.
 It has a pleasant odor
 It is non – irritating to the body.
 It is non – explosive & non – inflammable but will support combustion.

PHARMACOKINETICS:

- It is rapidly absorbed.

- When the agent is discontinued, recovery occurs quickly as the concentration of the
agent falls.

- Nitrous oxide has a high MAC compared with most volatile anesthetic agent.

- The nitrous oxide molecule is excreted unchanged almost exclusively by the lungs. It is
therefore suitable for patients with advanced liver or kidney diseases.

- It has little effect on the respiratory system as it is non – irritant & does not increase
bronchial secretions or depress respiration centrally.
Planes Definition Implication

Plane I - Moderate sedation & analgesia clinically useful for

- Usually obtained with concentration of dental sedation
5 – 25 % N2O

Plane II - Dissociation sedation & analgesia clinically useful for

-Usually obtained with concentration of dental sedation
20 – 55 % N2O

Plane III - Total analgesia considered to be too

-Usually obtained with concentration of close to anesthesia to
50 – 70 % N2O be safe in the dental
outpatient setting
 PROPERTIES:
Induction characteristics Smooth
Anxiolysis Yes
Cardio respiratory stability Stable
Ease of titration Easy
Induction & recovery rate Rapid
Metabolism < 1%
Ease of breathing Non – pungent
Blood gas solubility Low ( 0.47)
Potency (MAC) Weak (105 %)
Speed of change in sedation level Rapid
Systemic toxicity Yes (prolong use)
Environmental effects Yes
Analgesia Yes
ADVANTAGES:
 Ability to titrate
 Ability to reverse
 Controlled duration of action
 Rapid onset
 Rapid recovery
 Patient may be discharged alone.

DISADVANTAGES:
 Patient acceptance is not universe
 Cost of equipment not always effective
 It produces reversible inhibition of the enzyme methionine synthetase which is
involved in the synthesis of vitamin B
 On prolong use can cause bone marrow depression
 Increase in the rate of miscarriage among women dentists & dental nurses who are
exposed to nitrous oxide for prolong period of time.
SUPPLIED AS:

Nitrous oxide is supplied in a blue cylinder in both gas & liquid phase at a
pressure of 5400 kPa (800 psi). Oxygen comes as compressed gas in a black
cylinder with a white shoulder at a pressure of 15,000 kPa (2000 psi).
 Equipment
Mobile Self-Contained Units:
Various sources of leaks from anesthetic delivery systems in dental operatories
Central Supply:
 SEVOFLURANE

 It is a fluorinated derivative of methyl isopropyl ether which was first

synthesized in the early 1970s.

 It is pleasant to inhale, non – irritant & non – pungent.

 It is partly metabolized and so some care is required in people with severe liver
or kidney disease.
PROPERTIES:

Induction characteristics Smooth

Anxiolysis Yes
Cardio respiratory stability Stable
Ease of titration Easy
Induction & recovery rate Rapid
Metabolism 5%
Ease of breathing Non – pungent
Blood gas solubility Low ( 0.6)
Potency (MAC) High (2 %)
Speed of change in sedation level Fairly rapid
Systemic toxicity Not known
Environmental effects Minimal
Analgesia No
A specially calibrated vaporizer is required in order to titrate low concentrations of
sevoflurane.
Basic Circle Breathing System
 Essential components of a circle breathing system.
-Principles of Anesthesiology: general and regional anesthesia, Collins, Vincent J.,
Cann, Carroll C., 1993.
Chloral Hydrate:
Etomidate:
Midazolam:
Lorazepam:
Fentanyl:
Propofol:
Ketamine:
 Routes of Administration

a) Inhalational
b) Enteral
- Oral
- Rectal
c) Parenteral
- Subcutaneous
- Submucosal
- Intramuscular
- Intra-/Sublingual
- Intravenous
ROUTE FEATURES ADVANTAGES DISADVANTAGES/
LIMITATIONS

INHALATIONAL -2nd commonest mode -helps remove fears -Slightly raises pain
-N2O & O2 most -anxiolytic threshold
commonly used -increases tolerance to -cannot be used to
long procedures control a defiant,
-little/ no cardiotoxicity hysterical child

ORAL -Commonest mode for -easy administration -compliance –ve in

pediatric patients -patient compliance +ve cases of very young
-universally acceptable patients (tablets??)
-decreased incidence of -prolonged onset of
hypersensitivity action
reactions -erratic absorption

SUBCUTANEOUS -useful for non-volatile, -fair delivery and -slower rate of

H2O/fat actions absorption
solublesedatives -fear of needle prick
-avoid using Diazepam

SUBMUCOSAL … Maxillary posterior -uptake is very rapid -depth of syringe

region of the jaw… -very little patient co- should be limited
operation required -possibility of sloughing
& necrosis of
submucosal tissues.
ROUTE FEATURES ADVANTAGES DISADVANTAGES

SUBLINGUAL/ -restricted nly for -very rapid uptake (~35 -quite painful
INTRALINGUAL emergency use sec) -Nicholas & -titration of drug not
Curtright et al possible

INTRA- -least commonly used -more rapid onset than -titration of drug not
MUSCULAR -SITES: enteral route possible
~Outermost superior -reaches maximal effect -toxicity and
quadrant of buttocks in the 1st 30 minutes hypersensitivity
~Anterior aspect of mid- reactions are
thigh region comparatively on a rise.
~Deltoid region (in older
patients only-mid of
posterolateral aspect)
~Anterolateral region of
Vastus lateralisi n the thigh

INTRAVENOUS -most effective mode to -rapid onset of action -Problems related to

ensure predictable& (~20-25 sec) overdose, side effects &
adequate sedation allergic reactions are
-applied to highly anxious quite common.
but co-operative adult,
older children or
adolescent paients.
American Society of Anesthesiologists (ASA) Patient Physical Status
Classification
 References
1) Textbook of Pharmacology
–K.D. Tripathi

2) Dentistry for the Child & Adolescent

–McDonald & Avery

3) Procedural sedation and analgesia in children, Lancet 2006; 367: 766–80

4) ADA guidelines for the Use of Sedation and General Anesthesia by Dentists As
adopted by the October 2007 ADA House of Delegates.

5) Pediatric Moderate Sedation Illinois Emergency Medical Services for Children

February 2008.

6) Practice Guidelines for Sedation and Analgesia by Non Anesthesiologists,

Anesthesiology 2002; 96:1004–17
Thank you