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ANESTHESIOLOGY II (DANS412) Dr. Dixie Jill S. Yee 4th Year - 2nd Semester LABORATORY: CANNULATION PROCEDURES Intravenous cannulation is a technique in which a ○ Position patient in comfortable position with cannula is pla...

ANESTHESIOLOGY II (DANS412) Dr. Dixie Jill S. Yee 4th Year - 2nd Semester LABORATORY: CANNULATION PROCEDURES Intravenous cannulation is a technique in which a ○ Position patient in comfortable position with cannula is placed inside a vein to provide venous arm in dependent position access. ○ Tie the tourniquet 6’’ (15cm) above the R intended site ○ Palpate for the vein. If vein not dilated follow one of the techniques: O Gently tap over the vein Stroke upwards towards the tourniquet Instruct patient to open & close fist ST ○ Wear gloves Purpose: ○ Choose appropriate size of branula ○ Obtaining blood samples according to patient and indication for ○ Administration of fluid, medication, cannulation parenteral nutrition, chemotherapy, and CA blood products ○ Blood donation and dialysis Pre Cannulation Requirements: Branula ○ Clean the puncture site with alcohol swab Tegaderm / Plaster LE 5-10cm diameters starting from the site Alcohol swab outwards and let it dry. Gloves ○ Press lightly the vein using the thumb of the Tourniquet non dominant hand about 4cm below the IV stopper or tubing set intended site. Splint (if necessary) ○ Stretch the skin taut below the site of O Heparin saline or drip insertion with the thumb to stabilize the vein. ○ Hold cannula with bevel facing up and perform cannulation. IC ○ Observe the presence of back flow, no haematoma or thrombosis. ○ Connect cannula to IVD or put stopper and flush line. ○ Secure branula with plaster or tegaderm. CN Pre procedures: ○ Check for doctor’s order Post Cannulation ○ Greet and explain procedures to patient Post procedures: ○ Assess patient’s level of consciousness and ○ Discard all disposable items and sharps anxiety appropriately RI ○ Provide privacy ○ Wash hands ○ Documentation During Cannulation During procedures: ○ Wash hands ○ Select the site and vein No wound or rashes Vein is big enough, straight, soft and visible through the skin |1  F1: COMPLICATIONS OF INTRAVENOUS THERAPY HEMATOMA Principles of IV Therapy Hematoma and ecchymosis demote formations resulting from the infiltration of blood into the tissues at the venipuncture site: ○ Related to venipuncture technique ○ Use of large bore cannula: Trauma to the vein during insertion ○ Patients receiving anticoagulant therapy and long term steroids R - Hematoma is just bruising and Ecchymosis is just a bigger hematoma. This is not a serious complication, but rather a normal complication. O Subcutaneous hematoma is the most common complication Can be a starting point for other complications: ST Complications of IV Therapy Thrombophlebitis and Infection Related to: Classified according to their location ○ Nicking the vein A. Local complication: at or near the ○ Discontinuing the IV without apply adequate insertions site or as a result of mechanical pressure failure CA ○ Applying the tourniquet too tightly above a B. Systemic complications: occur within the previously attempted venipuncture site vascular system, remote from the IV site. Signs and Symptoms Can be serious and life threatening ○ Discoloration of the skin - more dangerous this involves our ○ Site swelling and discomfort circulatory system ○ Inability to advance the cannula all the way into the vein during insertion Local Complications ○ Resistance to positive pressure during the LE Occur as adverse reactions or trauma to the lock flushing procedure surrounding venipuncture site Prevention Assessing and monitoring are the key components to ○ Use of an indirect method early intervention - insert the needle beside the vein Good venipuncture technique is the main factor - vs. direct method where needle is inserted O related to the prevention of most local complications above the vein associated with IV Therapy. ○ Apply tourniquet just before venipuncture Local complications include: - use gloves as an alternative if tourniquet is IC 1. Hematoma not available 2. Thrombosis ○ Use a small needle in the elderly and 3. Phlebitis patients on steroids, or patients with thin 4. Postinfusion phlebitis skin. 5. Thrombophlebitis ○ Use blood pressure cuff to apply pressure CN 6. Infiltration ○ Be gentle 7. Extravasation Treatment 8. Local infection ○ Apply direct, light pressure for 2-3 minutes 9. Veno spasm after needle removed ○ Have patient elevate extremity ○ Apply Ice RI THROMBOSIS Catheter-related obstructions can be mechanical or non-thrombotic Trauma to the endothelial cells of the venous wall causes red blood cells to adhere to the vein wall, - Tunica Adventitia: outermost covering of the vein forms a clot or thrombosis - Tunica Media: middle portion Drip rate slows, line does not flush easily, resistance - Tunica Intima: inner covering of the vein lined with is felt endothelium Never forcible flush a catheter |2  - Thrombosis is a blood clot which makes the line not Treatment easily flushed. Do not forcibly flush because the blood ○ Never flush a cannula to remove an clot will go to the blood circulation occlusion ○ Discontinue the cannula ○ Notify the physician and assess the site for Types of Thrombus or Occlusion circulatory impairment a. Persistent withdrawal occlusion b. Partial occlusion PHLEBITIS c. Complete occlusion d. Fibrin tail Inflammation of the vein in which the endothelial cells R e. Fibrin sheath of the venous wall become irritated and cells roughen, f. Mural thrombosis allowing platelets to adhere and predispose the vein to inflammation-induced phlebitis O ○ S/S: Tender to touch and can be very painful Immune system causes leukocytes to gather at the inflamed site ST Pyrogens stimulate the hypothalamus to raise body temperature - pyrogens are fever-inducing substance that usually derives from microorganisms - increased pyrogens will result to inflammation, CA shock, multi organ failure or even death Pyrogens stimulate bone marrow to release more leukocytes Redness and tenderness increase [Causes:] 1. Mechanical: ○ To large a catheter for the size of the vein ○ Manipulation of the catheter: improper LE stabilization 2. Chemical: vein becomes inflamed by irritating or vesicant solutions or medication ○ Irritation medication or solution ○ Improperly mixed or diluted O ○ Too-rapid infusion ○ Presence of particulate matter ○ The more acidic the IV solution, the greater IC the risk ○ Additives: Potassium ○ Type of material ○ Length of dwell: 30% by day 2, 39-40% by Thrombosis related to: day 3 (Macki and Ringer) CN ○ Hypertensive pt; blood backing up ○ The slower the rate of infusion, the less ○ Low flow rate irritation ○ Location of the IV cannula ○ Compression of the IV line for an extended period of time ○ Trauma to the wall of the vein RI Signs and Symptoms ○ Fever and Malaise ○ Slowed or stopped infusion rate ○ Inability to flush Prevention 3. Bacterial ○ Use pumps and controllers to manage flow ○ Also called Septic phlebitis: least common rate ○ Inflammation of the intima of the vein ○ Microdrip tubing for rate below50mL/hr ○ Contributing factors: ○ Avoid areas of flexion Poor aseptic technique ○ Use filters Failure to detect breaks in the integrity of ○ Avoid lower extremities the equipment |3  Poor insertion technique ○ Edema in the limbs Inadequate stabilization ○ Tender and cord like vein Failure to perform site assessment ○ Site warm to the touch Aseptic preparation of solutions ○ Visible red line above venipuncture site Hand washing and preparing the skin ○ Diminished arterial pulses ○ Mottling and cyanosis of the extremities Prevention PHLEBITIS POSTINFUSION ○ Use veins in the forearm rather than the Inflammation of the vein 48-96 hr after discontinued hands Factors that contribute: ○ Do not use veins in a joint R ○ Insertion technique ○ Assess site q 4 hr in adults, q 2 hr in children ○ Condition of the vein used ○ Catheter securement ○ Type, compatibility, pH of solution used ○ Infuse at rate prescribed O ○ Gauge, size, length, and material ○ Use the smallest size catheter to do the job ○ Dwell time ○ Proper dilution ○ Infrequent dressing change Septic thrombophlebitis can be prevented: ST ○ Host factors: age, gender, age and presence ○ Appropriate skin preparation of disease ○ Aseptic technique in the maintenance of Signs and Symptoms infusion ○ Redness at the site ○ Proper hand hygiene ○ Site warm to touch 60% from patients skin CA ○ Local swelling 35% from the line itself ○ Palpable cord along the vein 5% from hands ○ Sluggish infusion rate ○ Increase in basal temperature of 1 degree C or more INFILTRATION Prevention The inadvertent administration of a non-vesicant ○ Use larger veins for hypertonic solutions solution into surrounding tissue ○ Central lines for Infusions lasting longer than - there’s a leak of a non-vesicant solution– those LE 5 days solution that does not cause severe tissue damage - central lines are usually used in ICU like necrosis or ischemia Dislodgement of the catheter from the vein Second to phlebitis as a cause of IV therapy morbidity Related to: O ○ Puncture of the distal vein wall during access ○ Puncture of the vein wall by mechanical friction IC ○ Dislodgement of the catheter from the intima of the vein ○ Poor securement High delivery rate ○ Over Manipulation Signs and Symptoms CN ○ Coolness of the skin around site ○ Taut skin ○ Dependent edema ○ Absence of blood return ○ “Pinkish” blood return ○ Infusion rate slows RI THROMBOPHLEBITIS Complications fall into 3 categories: Thrombophlebitis denotes a two-fold injury: 1. Ulceration and possible tissue necrosis thrombosis and inflammation 2. Compartment syndrome Related to: 3. Reflex sympathetic dystrophy syndrome ○ Use of veins in the lower extremity ○ Use of hypertonic or highly acidic infusion solutions ○ Causes similar to those leading to phlebitis Signs and Symptoms ○ Sluggish flow rate |4  EXTRAVASATION Inadvertent administration of a vesicant solution into surrounding tissue ○ Vesicant is a fluid or medication that causes the formation of blisters, with subsequent sloughing of tissues occurring from the tissue necrosis Extravasations related to: ○ Puncture of the distal wall R ○ Mechanical friction ○ Dislodgement of the catheter Example of Vesicants O - Many chemotherapy drugs are vesicants - Vancomycin ○ Phenergan pH is 4 to 5.5 ST ○ Dilantin pH is 12 (Drano has a pH of 14) ○ High concentration KCL pH is 5 to 7.8 ○ Calcium gluconate pH is 6.2 ○ Amphotericin B pH is 5.7 to 8 ○ Dopamine pH is 2.5 to 5 CA ○ Nipride pH is 3.5 to 6 ○ 10%, 20% or 50% dextrose pH is 3.5 to 6.5 ○ Sodium bicarbonate pH is 7 to 8.5 Signs and Symptoms ○ Complaints of pain or burning ○ Swelling proximal to or distal to the IV site ○ Puffiness of the dependent part of the limb ○ Skin tightness at the venipuncture site LE ○ Blanching and coolness of the skin ○ Slow or stopped infusion ○ Damp or wet dressing Prevention ○ Use of skilled practitioners O ○ Knowledge of vesicants ○ Condition of the patients veins ○ Drug administration technique IC If continuous give in CVAD + Central venous access devices (CVADs) or central venous catheters (CVCs) are devices that are inserted into the body through a vein to enable the administration of fluids, blood products, CN medication and other therapies directly to the major veins/ bloodstream. Only with brisk blood return of 3-5 cc Use of a free flow IV Do not use a pump on vesicants given peripherally Assess for blood return frequently Other Complications: RI ○ Site of venous access LOCAL INFECTION: ○ Condition of the patient ○ Microbial contamination of the cannula or the Vomiting, coughing, retchin infusate Sedated ○ Thrombus becomes infected Unable to communicate VENOUS SPASM: a sudden involuntary contraction of a vein or an artery resulting in temporary cessation of blood flow through a vessel - S/S: sharp pain at the IV site that travels up to the arm - TX: Slow down the infusion |5  F2: CONSCIOUS SEDATION Side effects of conscious sedation ~ Definition of terms ~ drowsiness Analgesia: any drug that relieves pain selectively feelings of heaviness or sluggishness without blocking the conduction of nerve impulses, loss of memory of what happened during the markedly altering sensory perception, or affecting procedure (amnesia) consciousness. AKA Painkillers slow reflexes - e.g. NSAIDs, Paracetamol low blood pressure Anesthesia: loss of sensation with or without loss of headache consciousness. feeling sick R - general term, has 2 types: Local and General Local anesthesia: the elimination of sensation, Recovery is quick conscious sedation especially pain, in one part of the body by topical O application or regional injection of drug You may need to stay in the procedure or operating General anesthesia: the elimination of all sensation, room for up to an hour, maybe more. Your doctor or accompanied by the loss of consciousness dentist will usually monitor your heart rate, breathing, ST Conscious sedation: a minimally depressed level of and blood pressure until they're back to normal. consciousness that retains the patient's ability to Bring a family member or friend who can drive or take independently and continuously maintain an airway you home. You can usually drive once some forms of and respond appropriately to physical stimulation and sedation, such as nitrous oxide, wear off. However, verbal command and that is produced by this isn't always the case for other forms. CA pharmacological or non pharmacological method or Some side effects may last for the rest of the day. combination thereof. These include drowsiness, headaches, nausea, and - px is awake. They are aware, just a bit groggy, but sluggishness. they can still respond depending on the level of the sedation Conscious Sedation vs General Sedation - very common abroad, very price-y here in the PH : Conscious sedation helps reduce anxiety, discomfort, and pain during certain procedures. LE : Commonly used in dentistry for people who feel anxious or panicked during complex procedures like fillings, root canals, or routine cleanings. It's also often used during endoscopies and minor surgical procedures to relax patients and minimize discomfort O : In the past, it's been called: sleep dentistry twilight sleep IC happy gas laughing gas happy air CN What does conscious sedation feel like? Sedation effects differ from person to person. The Level of Sedation most common feelings are drowsiness and relaxation. Once the sedative takes effect, negative emotions, 1. Minimal Sedation (Anxiolysis) is a drug-induced stress, or anxiety may also gradually disappear. state during which patients respond normally to verbal You may feel a tingling sensation throughout your commands. Although cognitive function and physical RI body, especially in your arms, legs, hands, and feet. coordination may be impaired, airway reflexes, and This may be accompanied by a heaviness or ventilatory and cardiovascular functions are sluggishness that makes it feel harder to lift or move unaffected. your limbs. You may find that the world around you slows down. 2. Moderate sedation is a drug-induced depression of Your reflexes are delayed, and you may respond or consciousness during which patients respond react more slowly to physical stimuli or to purposefully to verbal commands, either alone or conversation. You may even start smiling or laughing accompanied by light tactile stimulation. NO without an obvious cause. They call nitrous oxide interventions are required to maintain a patent airway, laughing gas for a reason! and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. |6  3. Deep Sedation/Analgesia is a drug-induced Complications Associated with depression of consciousness during which patients Moderate or Deep Sedation cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to 1. Ineffective ventilation resulting from airway independently maintain ventilatory function may be obstruction, respiratory depression causing hypoxia impaired. Patients may require assistance in and hypercarbia. maintaining a patent airway, and spontaneous 2. Problems with the cardiovascular system including ventilation may be inadequate. hypotension Cardiovascular function is usually maintained. 3. Drug overdose or reaction (anaphylaxis or anaphylactoid reactions) R 4. Aspiration associated with loss of protective airway Guidelines: reflexes. 1. Patients less than 2 years old - may take clear 5. Nausea and vomiting. O liquids up to 2 hours before the procedure and may 6. Problems with equipment compromising patient take solids (nonhuman milk) up to 6 hours before the safety. procedure. ST 2. Patients greater than 2 years old (including adults) - Airway Obstruction may take clear liquids up to 2 hours before procedure most common complication associated with moderate and may take solid up to 8 hours before procedure. sedation. 3. Clear liquids are defined as water, fruit juices without result from loss of tonicity of submandibular muscles, pulp, carbonated beverages, clear tea and black direct CA coffee. The volume of liquid ingested is less important support to the tongue and loss of indirect support to than the type of liquid ingested. the epiglottis. 4. While the ASA suggests that patients may have a light meal up to 6 hours before a procedure, a light Signs of Airway Obstruction: meal is defined typically as toast and clear liquids. 1. Inspiratory stridor or snoring Heavier meals that include fried or fatty foods or meat 2. Sternal retraction may prolong gastric emptying and require a longer 3. Rocking chest movements fasting period. LE 4. Absence of breath sounds - patient needs to fast to allow gastric emptying before 5. Hypoxemia (e.g. drop in oxygen saturation) the procedure is present when PaO2 is less than 60 mmHg or SpO2 by pulse oximeter is less than 90%. Clinical conditions that may delay gastric emptying and - decreased oxygen in the bloodstream increase their risk of aspiration include: Clinically, patients may become agitated before O Anxiety cyanosis of mucous membranes occurs. Severe pain Causes: – Hypoventilation IC Autonomic dysfunction (gastroparesis) Hiatal hernia / GERD – Low inspired oxygen Morbid obesity – Increased oxygen consumption Pregnancy (e.g. shivering, sepsis, pain) Bowel obstruction – Low cardiac output CN Multi-trauma – Anatomic shunt: refractory to oxygen Head trauma / increased intracranial pressure therapy Ascites 6. Hypercarbia Peritoneal dialysis the usual source of hypercarbia is respiratory center Oral x-ray contrast depression from medications - increased carbon dioxide in the bloodstream RI In urgent or other situations in which gastric emptying PaCO2 greater than 44 mmHg and is the result of is impaired, the potential for pulmonary aspiration of hypoventilation. gastric contents must be considered in determining: - may be caused by high doses of benzodiazepine or 1. The target level of sedation narcotics 2. Whether the procedure should be delayed Treatment of Ventilatory or Airway Compromise: 3. Whether the trachea should be protected by 1. Provide supplemental oxygen if not already being intubation administered. 2. If airway obstruction is suspected consider: - there are usually not many complications associated with a. Repositioning the patient's head minimal sedation since this is light. b. Providing a head tilt |7  c. Applying a chin lift or jaw thrust Nausea and vomiting is the leading cause of 3. Consider oversedation from medication therefore unexpected hospital admission. suspend further drug administration and support and Predisposing factors of nausea and vomiting are: maintain the patient's airway by the maneuvers above and consider the use of reversal agents like naloxone 1. Age (younger patient more susceptible) or flumazenil. 2. Female gender 4. Should the above not correct the situation consider 3. History of postoperative emesis bag-mask positive ventilation and even intubation. 4. Presence of hypoglycemia, pain, hypotension, or hypoxia. R Anaphylaxis and Anaphylactoid Reactions Treatment of Nausea and Vomiting are acute and are characterized by wheezing, 1. Evaluate and treat causes of hypoglycemia, pain, dyspnea, syncope, hypotension, and upper airway hypoxia, or hypotension O obstruction 2. Metoclopramide (Reglan) Histamine release can be – Adult: 10-20 mg. IV ○ produced by administration of morphine and – Pediatric 0.15 mg/kg IV ST other agents 3. Ondansetron (Zofran) - drug allergy – Adult: 4-12 mg. IV ○ Latex allergy – Pediatric - gloves, rubber dam sheet, tube 4. Droperidol* Treatment of Anaphylactic and Anaphylactoid Reactions – Adult: 0.625-1.25 mg IV CA – Pediatric: 0.01-0.02 mg/kg IV 1. Prompt recognition of the clinical situation and stopping the administration of the suspected offending drug. 2. Ventilation with 100% oxygen. Securing the airway with endotracheal intubation may be necessary. 3. Prompt use of fluids and epinephrine (IV or SQ) and antihistamines. LE - IV is better for faster effect in cases of emergency 4. Supportive care Types of Sedation Aspiration ORAL SEDATION O During deep sedation where airway protective involves taking a prescribed dose of sedative before reflexes are lost, aspiration is a risk. the procedure Risk factors for aspiration: IC Depending on the case, the patient may take one pill 1. Inadequate fasting or recent oral intake the night before, and one pill an hour before the 2. Diabetes (presence of autonomic dysfunction) procedure, or otherwise as directed by the dentist 3. Pregnancy This type of sedation leaves the patient awake for the 4. Gastric reflux procedure, but significantly gives a relaxing feeling. CN 5. Altered consciousness Advantages Disadvantages Diagnosis of Aspiration: 1. Suspect aspiration in patients with the above risk Almost universally Reliance on patient factors having respiratory difficulty, tachypnea, acceptability compliance tachycardia, cyanosis and oxygen desaturation. Ease of administration, Prolonged latent period 2. Blood gasses may reveal hypoxemia with mixed convenience = Low cost - average: 30-60 secs RI metabolic and variable respiratory acidosis. Decrease incidence of Erratic and incomplete 3. In severe cases of aspiration: systemic hypotension, adverse reaction absorption of drug from Gl pulmonary hypertension and pulmonary edema may Decrease severity of tract occur. adverse reaction Inability to titrate 4. Radiographic findings are variable No needles, syringes, - level of sedation can’t equipment be controlled; fixed dosage No specialized training Inability to readily lighten or Nausea and Vomiting deepen the level of sedation can cause hypertension or hypotension, tachycardia, - dentist has to have S2 license to prescribe this kind of drug bradycardia and aspiration. |8  RECTAL SEDATION Other potential factors, not to be used in an effort Interest in the rectal route of drug administration has such as adsorption by feces, to achieve deep sedation increased in anesthesiology and, to a lesser extent, in intraluminal degradation by unless the dentist is well dentistry in recent years. microorganisms, metabolism versed in general anesthesia - usually for kids within the mucosal cell, and and in airway management Historically the rectal route of drug administration was lymphatic drainage, do not of the unconscious patient. used for the administration of smoke ("fumigation") significantly affect the fate of The recommended use of for resuscitation and the administration of anesthetics rectally administered drugs. rectal sedation is for the induction of minimal to R moderate sedation when other, more controllable methods of anxiety control O (IV, inhalation) may be added if needed during treatment. ST - parang CPR daw sa pwet lol Fumigation method: This process involved propelling tobacco INTRAMUSCULAR SEDATION smoke up the lifeless victim's rectum. Unfortunately, the victim would often go on to develop COPD (colon obstructive a parenteral technique in which the drug enters the peristalsis disease). Not surprisingly, this directional process of cardiovascular system without first passing through CA blowing smoke is still used today by some QA and operational the gastrointestinal (Gl) tract. managers. - more indicated for pediatrics since this require less include the administration of a drug to a patient who is patient cooperation; compared to IV and Inhalation unwilling or unable to take drugs orally. In most sedation which requires more patient cooperation to instances, this is a child or an adult with a disability be successful requiring sedation either to permit treatment to - if the child is still not being cooperative via IM, then proceed or as a preliminary to the induction of general opt to general anesthesia anesthesia LE Advantages Disadvantages - indicated for px with needle phobia who can’t take meds orally Rapid onset of action (15 Inability to titrate* (15-min Another situation in which rectal drugs are warranted min) onset) is the administration of antiemetics to patients with Maximal clinical effect (30 Inability to reverse drug nausea and vomiting. min) action O Although parenteral administration is preferred (if the More reliable absorption Prolonged duration of drug patient is present in the office where the drug may be (than oral, rectal) effect injected), rectal administration can be used if the Patient cooperation not as Injection needed IC patient objects to injection or if the patient is at home. essential Possible injury from Another indication for rectal administration of drugs is injection (rare) analgesics for postoperative control of pain. * inability to titrate makes it hard to get the desired clinical Advantages Disadvantages effect. the dentist is unable to consistently predict the proper CN dose to administer in any given px, leading to the use of rapid onset of clinical inconvenience to the uneducated guess, based on a number of factors to be activity administrator and the patient discussed. although the dose is often appropriate, some decreased incidence and variable absorption of situation can occur in which the calculated dose is ineffective, intensity of drug-related side some drugs from the large leading to inability to treat the patient; or more significant effects intestine, possible irritation however are those occasions when the calculated dose has the lack of a needle, of the intestines by some RI proven too great for the patient leading to possibly bad syringe, or other potentially drugs consequence for both the patient and the dentist threatening equipment; the inability to reverse the avoidance of an injection action of the drug easily ease of administration prolonged recovery with Sites of IM drug administration: (many children who some drugs, and an inability Gluteal Area vehemently object to the oral to titrate precise individual The upper outer quadrant of the gluteal region is the route will not object to this doses. most commonly used site for IM drug administration in route) clinical sedation is evident adults. low cost at 15 to 30 minutes |9  Of the 4 available IM injection sites, the gluteal Deltoid region is the least well perfused, having 20% lower easy access in most patients perfusion than the deltoid. more rapid absorption of the injected drug into the Because perfusion is the rate-limiting step in the cardiovascular system than is seen with any of the absorption of IM drugs, the rate of onset of action of other IM injection sites. Perfusion is 20% greater in drugs administered in the gluteal region is somewhat the deltoid region than in the gluteal region. slower than when alternative sites are used. It is only able to accommodate only up to 4 ml of The gluteal region extends superiorly to solution (adult). However, this is not of significance in the anterior superior iliac spine. With this dentistry because it is rare to ever administer more as a landmark, the region is divided into than 3 ml intramuscularly. R quadrants. The upper outer quadrant is Giovannitti and Trapp suggest the deltoid the most anatomically safe because it is muscle as the preferred site for IM sedation distant from the sciatic nerve and the in the dental environment. O superior gluteal artery. The lower inner aspect of the upper outer quadrant is the The deltoid muscle is easily accessible in the preferred site within this quadrant. upper third of the arm. The injection is given ST - if the sciatic nerve is nicked, the patient between the upper and lower portions of the may experience paralysis. So always inject on the UOQ to deltoid muscle, thereby avoiding the radial avoid hitting the nerve. nerve. - the sciatic nerve is one of the longest nerves of the body. - this method is now avoided esp. by pediatric doctors, since CA the rate of absorption is slow and there is a risk of hitting a vital SUBMUCOSAL SEDATION structure used in pediatric dentistry. Ventrogluteal Region CNS-depressant drug is injected into the mucous lies in close proximity to the gluteal region. Its membrane in either the maxillary or mandibular primary use is for IM injection in patients who are buccal fold. bedridden and unable to lie face down. An advantage of SM administration over IM The site is located among three bony administration is a slightly more rapid onset of clinical LE landmarks that are usually quite readily action. palpated. These are the anterior superior iliac spine, the iliac crest, and the greater INHALATION SEDATION trochanter of the femur. Anatomically, this - Most expensive but the best method since there are region lies at some distance from the O less complications that may arise sciatic nerve and other anatomically History: important structures. → Nitrous oxide was first discovered by Joseph - quite far from the sciatic nerve, so this Priestley in 1772. IC is safer than the gluteal → In 1795, Humphry Davy and surgeon J. B. Borlase - form a V then inject in the middle, below the iliac crest experimented with nitrous oxide and the effects of its inhalation. Davy then published a book in 1799 hinting Vastus Lateralis at the possible role of nitrous oxide in achieving mild strongly recommended for use in small children. CN anesthesia during surgical procedures. The safest region in which to deposit IM drugs. → In 1831, Chloroform was discovered by Justus von The vastus lateralis can accommodate volumes of Liebig in Germany, Samuel Guthrie in New York and solution up to 15 ml, whereas the gluteal and Eugène Soubeiran in France, all of whom worked ventrogluteal can accommodate approximately 4 to 8 independently. ml each before muscle distortion and dissection → In 1842, a chemist in Rochester, William Edward occur, leading to increased pain during and after RI Clarke provided Dr. Elijah Pope with ether prior to a injection. tooth extraction of his patient. In the same year, a - very common for pediatrics nowadays doctor in Georgia, Dr. Crawford W. Long administered since this is the safest method ether to John Venable for the removal of a neck - anatomically, the vastus lateralis tumor. contains no vital structure → In 1844, Dr. Horace Wells carried out an - the only complication that may arise is experiment on himself where he had Professor when you overly deepen the Gardner Quincy Colton administer nitrous oxide to penetration of the needle that it may hit himself prior to a wisdom tooth extraction by Dr. John the femur Riggs. Wells discovered that he was unaware of the | 10  procedure and experienced absolutely no pain during Advantages: the procedure. Inhalation sedatives is a form of conscious sedation Onset of action is more rapid than that of oral, rectal, where an inhaled drug should intranasal (IN), or intramuscular (IM) sedation. The a. Depress the central nervous system (CNS) onset of action of IV medications is approximately, but to an extent that allows operative treatment not quite, equal to that of inhalation sedation. to be carried out with minimal physiological Only inhalation and IV drug administration provide and psychological stress peak clinical actions in a time span permitting titration. b. Modify the patient's state of mind such that Depth of sedation achieved with inhalation sedation communication is maintained and the patient may be altered from moment to moment, permitting R can respond to verbal command the drug administrator to increase or decrease the c. Carry a margin of safety wide enough to depth of sedation. render the unintended loss of consciousness Recovery time from inhalation sedation is rapid. O and loss of protective reflexes unlikely. Because N20 is not metabolized by the body, the gas is rapidly and virtually completely eliminated from the body within 3-5 minutes. ST The drugs used in this technique have no adverse effects on the liver, kidneys, brain, or cardiovascular and respiratory systems. Inhalation sedation with N2O-O2 can be used instead of local anesthesia in certain procedures. The CA analgesia produced by a 20% concentration of N20 is At a concentration of 30% to 40%, N20 produces the equivalent to that of 10 to 15 mg of morphine. maximum degree of analgesia, while the patient However, the degree of analgesia is quite variable remains able to respond to verbal commands from patient to patient and therefore cannot be relied - a mixture of Nitrous Oxide and Oxygen on to provide all of the pain control required for a - Nitrous Oxide is a colorless and odorless gas, with procedure. Certain procedures, such as those faint sweet smell involving soft tissues (scaling, curettage), may be - Universal Color Code: performed in many instances without using LA. LE - Nitrous Oxide is BLUE - Oxygen is GREEN or BLACK Disadvantages: The initial cost of the equipment required for - HOW to administer inhalation sedation? inhalation sedation is high. - Before introducing nitrous oxide, give 100% oxygen A degree of cooperation is required from the patient. first while slowly allowing the patient to breathe at an O For inhalation sedation to be effective, the px must be established flow rate of 5-6 liters per minute, generally able to inhale the gasses through either the nose acceptable via nasal route. When it is used in combination with at least 20% O2, - Then do titration technique, which is regarded as the IC there will be a small percentage of patients in whom current standard of care when administering nitrous oxide. the technique will fail to produce the desired clinical Introducing the 10-20% nitrous oxide, the gas is then titrated actions. In NO circumstance should N2O ever be via increment of 5-10% every 1-3 minutes until the desired administered with less than 20% O2 level of clinical sedation is achieved. - oxygen should always be at least 50-70% CN - Increase the nitrous oxide increment by increment All members of the sedation team employing N20-02 until the standard nitrous oxide is reached: 30-40% nitrous must receive training in its safe and effective use. oxide is needed to reach ideal sedation Nausea and vomiting are the most frequent - Nitrous oxide delivered at a concentration should complications associated with N20-02 therapy. always only be less than 50%, otherwise the patient would - Leaking of N2O from the tank is dangerous since this die. cannot be detected because it is odorless. Prolonged RI - While administering N2O, slowly decrease the exposure to N2O can cause spontaneous abortion. oxygen until it reaches 70%. So the mixture should be 30-40% N20 and 70% O2. Indications: - Once the procedure is done, administer 100% Anxiety oxygen again for at least 5 minutes before ending the Medically compromised patient: procedure or until the patient no longer exhibits any clinical – cardiovascular disease, stroke, hepatic disease signs of sedation. Pregnancy - While administering O2, decrease the nitrous oxide Allergy until it’s gone. – there has never been reported allergic to N2O - When the patient has completely recovered from the Gagging effects of N2O, the patient may then be dismissed. | 11  INTRAVENOUS SEDATION GENERAL ANESTHESIA The administration of sedation agents via the Since general anesthesia first became widely used in intravenous (IV) route normally produces a late 1846, assessment of anesthetic depth was a predictable and reliable pharmacological effect problem. To determine the depth of anesthesia, the - the fastest route, most predictable since anesthetist relies on a series of physical signs of the anesthesiologist can control the dosage and onset of patient. In 1847, John Snow (1813-1858) and Francis sedation as well as the time when is the patient gonna Plomley attempted to describe various stages of wake up general anesthesia. - vs. other route which are fixed, cannot be titrated Guedel in 1937 described a detailed system which R Indications: was generally accepted: Moderate to severe dental anxiety Stage 1: O Traumatic surgical procedures ANALGESIA Gag reflex and swallow reflex are present Mild medical conditions which may be aggravated by Characterized by the development of analgesia or reduced sensation to pain. The patient is conscious ST the stress of dental treatment, for example mild hypertension or asthma and can still respond to command. Reflexes are Mild intellectual or physical disability, for example mild present, and respiration remains regular. Some learning disability, cerebral palsy. amnesia may also be evident. Nitrous oxide, as used in the dental office, keeps the Contraindications: patient on stage. The end of this stage is marked by CA History of allergy to benzodiazepines the loss of consciousness. Impaired renal or hepatic systems Pregnancy and breastfeeding Stage 2: Severe psychiatric disease DELIRIUM or EXCITEMENT Drug dependency Begins with unconsciousness and is associated with For people with severe needle phobia who are unable involuntary movement and excitement. Respiration to accept any type of injection, inhalation, oral LE becomes irregular (tachycardia), and muscle tone sedation or intranasal sedation may be acceptable increases. alternatives. For these patients it is sometimes Sympathetic stimulation produces tachycardia, necessary to combine 2 techniques. Inhalation mydriasis, and hypertension. This can be an sedation (or even hypnosis) may be employed initially uncomfortable time for the patient because emesis to relax the patient enough to allow venous and incontinence can occur. As the depth of O cannulation; once the cannula has been inserted, the anesthesia increases, the patient begins to relax and inhalation element of the sedation is switched off and proceeds to stage Ill. To ensure the patient's comfort the IV sedative can be administered. and safety, it is important to have a smooth and rapid IC The use of IV techniques is limited in patients with induction. poor veins. This includes patients with excessive The ultrashort-acting barbiturates accomplish this subcutaneous fat, whose veins are not visible, and readily. When balanced anesthesia is used, the the elderly who frequently have friable veins which patient does not pass through each stage as listed. are prone to damage during cannulation. Adjunct drugs reduce the side effects of each of the CN drugs used during surgery. Onset of Action Stage 3: ORAL 30 mins onset SURGICAL ANESTHESIA RECTAL 30 mins onset Stage Ill, is the stage in which the patient's pupillary RI gaze is central and the pupils are constricted. This is IM or IN 10 to 15 mins onset the target depth of surgical anesthesia. During this stage, the skeletal muscles relax, the IV 20 secs onset (appropriate arm-to-brain patient's breathing becomes regular, and eye circulation time) movements stop. 1 to 2 mins for clinical actions to develop - This is when the surgical procedures is being done INHALATION