Sedation Part 1 PDF

Sedation Dr. Anuroop Singhai Oral Surgery Division Intravenous Sedation Introduction Local Anesthesia: Traditional approach for most dental procedures. Sedation Needed For: Uncooperative children Adults with dental phobia Medically compromised patients (e.g., cardiov...

Sedation Dr. Anuroop Singhai Oral Surgery Division Intravenous Sedation Introduction Local Anesthesia: Traditional approach for most dental procedures. Sedation Needed For: Uncooperative children Adults with dental phobia Medically compromised patients (e.g., cardiovascular disease, asthma) Patients with fainting attacks or gagging issues General Anesthesia: Only for patients meeting ASA I & II criteria. Historical Context: Pioneers: Langa (nitrous oxide) and Jorgenson (IV agents). Techniques: Range from full consciousness to deep sedation. Levels of Sedation Sedation Level Description Airway & Response Minimally depressed consciousness; Conscious Independent airway; patient maintains airway and Sedation responsive to stimulation. responds to commands. Slightly depressed consciousness; Airway maintained; cognitive Minimal Sedation retains airway and normal response function slightly impaired. to touch and verbal cues. Drug-induced depression; purposeful Adequate spontaneous Moderate responses to commands; airway ventilation; hemodynamic Sedation maintenance unrequired. stability. Significant depression; may not easily Impaired ventilatory function; Deep Sedation arouse; requires assistance for airway may need airway support. maintenance. Complete loss of consciousness; not Impaired airway and General arousable, requires assistance for spontaneous ventilation; Anesthesia airway and ventilation. possible cardiovascular effects. Methods of IV Drug Administration Direct IV Administration: No vein patency maintenance. Drug injected directly into the vein after aspiration. Tourniquet applied, needle insertion, drug administration, site pressure. Needle Maintained in the Vein: Needle remains in place without continuous infusion. Periodic flushing to maintain patency. Engorge veins, insert needle, attach syringe, flush periodically. Methods of IV Drug Administration Continuous IV Infusion: Indwelling needle/catheter with connected IV solution. Continuous flow prevents occlusion during treatment. Standard venipuncture, secure catheter/tubing, adjust flow for consistency. Techniques of Sedation: Intravenous Sedation Advantages Disadvantages 1. Highly effective technique—smooth 1. Venipuncture is necessary induction 2. Venipuncture complications 2. Rapid onset of action (infiltration, hematoma, and 3. Titration is possible thrombophlebitis) may occur 4. Patent vein is a safety factor 3. More intensive monitoring required 5. Control of salivary secretions possible 4. Chances of delayed recovery 6. Nausea and vomiting less common 5. Escort needed 7. Gag reflex diminished 8. Motor disturbances (epilepsy, cerebral palsy) diminished Since IV sedation techniques may produce major depression of cardiorespiratory parameters, it is not to be administered to the patient by any person except those who have had training in anesthesiology. Drugs Commonly Available Drug Class Common Drugs Sedative, Hypnotics, and Antianxiety Drugs Benzodiazepines Diazepam, Midazolam Barbiturates Thiopentone, Methohexitone Nonbarbiturate Hypnotics Propofol, Ketamine, Etomidate Antihistaminics Promethazine Narcotic Agonists Pethidine, Pentazocine, Fentanyl Techniques of Sedation: Intravenous Sedation Midazolam: current agent Advantages: 1. Short-acting and potent 2. Excellent anxiolytic properties 3. Powerful anterograde amnesic effect Dosage: 0.03–0.05 mg/kg (useful sedation for ~45 mins) Monitoring & Safety: Essential Monitoring: Pulse oximetry for oxygen saturation Administer oxygen (1-2 LPM) via nasal cannulae Post-Procedure Care: Discharge criteria must be met Patient must be accompanied home Use of Flumazenil for benzodiazepine overdose Caution: Requires careful titration; maintain verbal contact with patient. Propofol Recent Advancements: Latest agent in clinical practice for anesthesia and sedation. Uses: Induction & maintenance of anesthesia Sedation for short dental procedures Key Benefits: Titration: Easily adjustable sedation levels via continuous infusion Rapid Recovery: Quick return to full orientation (5-10 mins post- infusion) Amnesia: At infusion rates >30 μg/kg/min Comparison: Faster onset/offset than midazolam Effective antiemetic properties at low doses Ideal for Day Care Settings: Minimizes hangover effects, allowing for swift patient turnover. Ketamine Hydrochloride What is Ketamine? Phencyclidine derivative & non-barbiturate hypnotic Produces dissociative anesthesia. Effects: 1. Sedation 2. Amnesia 3. Intense Analgesia High Safety Margin: Good tissue compatibility Minimal vein irritation Ideal for Dentistry: Maintains airway patency (tongue muscles remain tense) Airway obstruction typically mechanical (excess salivation, operator pressure) Ketamine Hydrochloride Clinical Considerations: Cardiovascular Effects: Increases heart rate & blood pressure; manage with benzodiazepines (midazolam 0.05–0.07 mg/kg IV) Avoid in: Patients with hypertension & ischemic heart disease Side Effects: 1. Transient respiratory depression 2. Increased intracranial/intraocular pressure 3. Nausea & vomiting Management Strategies: Use low doses for sedation & analgesia (0.1–0.5 mg/kg IV) Consider continuous infusion (10–20 μg/kg/min) to reduce side effects and recovery time Administer premedication to decrease emergence reactions (e.g., vivid dreams, hallucinations) Propofol and Ketamine: Combination Combination Benefits: Titrable Sedation: Tailored sedation levels for individual patient needs Intense Analgesia: Enhanced pain management during procedures Increased Hemodynamic Stability: Supports cardiovascular health Reduced Risks: Less Respiratory Depression: Safer airway management Low Incidence of Psychomimetic Effects: Minimizes adverse psychological reactions Dosage Guidelines: 1. Ketamine: 10–30 μg/kg/h 2. Propofol: 0.5–1.5 mg/kg/h Fentanyl: Ideal Narcotic for Dental Practice Advantages: Short Duration of Action: 30–45 minutes—perfect for outpatient procedures Hemodynamic Stability: Does not cause hypotension Considerations: Potential side effects at higher doses: 1. Bradycardia 2. Respiratory Depression 3. Nausea & Vomiting 4. Muscle Rigidity Sedation Protocol: Administer IV at 1–2 μg/kg Can be combined with sedatives/hypnotics: 1. Midazolam 2. Methohexitone 3. Propofol Neurolept Analgesia Definition: The term describes a state of indifference and immobilization where patient becomes pain free (analgesic), deeply sedated and partially or wholly amnesic, but yet remains capable of obeying commands and answering simple questions. Composition: This state is produced by the agent Innovar: Combination of: Droperidol: Tranquilizer & powerful antiemetic (effective up to 6 hours) Fentanyl: Narcotic (limited action, max 45 minutes) Limitations: Not Suitable for Outpatient Dental Practice: Due to prolonged effects Discouraged in Modern Anesthesia Practices Pethidine and Promethazine Combination Composition: Pethidine: Narcotic (50 mg) Promethazine (Phenergan): Antihistamine (25 mg) Dilution: 5 mg/mL of pethidine & 2.5 mg/mL of promethazine Administration: Dosage: 1–2 mL IV until adequate sedation is achieved Sedation Duration: Effect: 60–90 minutes Post-Procedure: Patient remains drowsy for several hours; delayed recovery Current Relevance: Abandoned Technique: Replaced by more easily titratable and shorter-acting alternatives Antidotal Drugs Importance of Antidotal Drugs: Essential for reversing adverse effects of sedative drugs. Categories: 1. Opioid Antagonists - Naloxone 2. Benzodiazepine Antagonists - Flumazenil 3. Emergence Delirium Reversal Agents - Physostigmine 4. Vasodilators for Extravascular/Intraarterial Administration - Procaine Emergency Kit Requirement: Each of these categories should be represented in the emergency kit of any doctor administering parenteral sedation by the subcutaneous (SC), IM, or IV routes or by IV general anesthesia. Antidotal Drugs Naloxone (Opioid Antagonist): Rapidly reverses opioid-induced respiratory depression. Administered IV or IM; effects seen within 1-2 minutes. Duration: ~30 minutes IV; longer with IM. Flumazenil (Benzodiazepine Antagonist): Quickly reverses benzodiazepine sedation. Administered IV; onset in 1-2 minutes. Max dose: 1 mg total over 5 minutes. Physostigmine: Reverses anticholinergic effects and emergence delirium. Administered IM or IV; onset within minutes. Procaine: Local anesthetic with vasodilating properties. Used for extravasation or intra-arterial drug administration. Complications Venipuncture Local Complications of General Drug-Related Complications Drug Administration Complications Nonrunning IV infusion Extravascular drug Nausea and vomiting Venospasm administration Localized allergy Hematoma Intraarterial injection Respiratory depression Infiltration Local venous Emergence delirium Local venous complications Laryngospasm complications Air embolism Overhydration Specific Drug Complications Complications Drugs Local venous complications Benzodiazepines Emergence delirium Benzodiazepines, Scopolamine Recurrence of amnesia Benzodiazepines Oversedation Benzodiazepines, Pentobarbital, Promethazine Respiratory depression Pentobarbital, Opioids Extrapyramidal reactions Promethazine Nausea and vomiting Opioids Rigid chest Opioids Thank You