Oral Sedation for the Adult Patient PDF

Oral Sedation for the Adult Patient Course #: DENTG 1831 Course Name: Oral Conscious Sedation Presenter: Trever Siu, DMD, MS, Associate Professor Presentation Date: 7 October 2024  Learning Objectives 1. Familiarize with the sequence of events associated with the oral sedat...

Oral Sedation for the Adult Patient Course #: DENTG 1831 Course Name: Oral Conscious Sedation Presenter: Trever Siu, DMD, MS, Associate Professor Presentation Date: 7 October 2024  Learning Objectives 1. Familiarize with the sequence of events associated with the oral sedation appointment for the adult patient. 2. Familiarize with the post-operative recovery, discharge and follow up protocols. 3. Recognize the signs & symptoms of appropriate sedation as well as over- & under-sedation. 4. Understand the rationale behind the use of various sedation drugs and monitoring systems. 5. Understand the requirements pertaining to the storage and record-keeping associated with controlled substances. 6. Familiarize with the options and cost associated with monitoring equipment. Primary Reference: Sedation (6th edition) by S. Malamed Chapter 7  References General concepts are referenced from Chapter 7 of the course textbook: Malamed 6th edition Arizona statutes - guidelines & regulations: 1303 permit https://apps.azsos.gov/public_services/Title_04/4-11.pdf ADA guidelines https://www.ada.org/~/media/ADA/Member%20Center/FIles/anesthesia_guidelines.pdf?la=en DEA Practitioner’s Manual https://www.deadiversion.usdoj.gov/pubs/manuals/pract/index.html  What does this “Appointment” look like ??  Oral Sedation Appointment In preparation for this appointment - Patient should have been evaluated at the consultation appointment to be a suitable candidate for oral sedation Review medical history Establish baseline vital signs Preoperative instructions reviewed, copy given to patient - Do not eat or drink 6 hours prior to treatment - Take all medications as usual - Bring an escort (18+ yrs) who will drive patient home - Wear loose clothing, avoid wearing makeup, jewelry & nail polish - If prescribed sedative, remind patient to pick them up/bring them! Take care of all consent forms at THIS APPOINTMENT.  Stress Reduction Strategies Aside from sedative drugs, consider these additional strategies to reduce the patient’s stress level: Wear loose, comfortable clothing Consider bringing personal entertainment (eg. book, magazine, audiobook, music, movie) Allow time for the patient to use the restrooms prior to starting treatment. Periodically engage the patient:  reassures patient  allow for continuous monitoring  assess for adequate sedation  Oral Sedation Appointment Day of the appointment Patient has been instructed to appear at the dental office 1 hour prior to the time of the scheduled treatment. Why?? Dentist or staff administers the sedative drug to patient with 8 oz of water in the absence of a meal. Patient should be kept in an area that allows for constant monitoring (e.g. waiting room, dental operatory)  Oral Sedation Appointment Day of the appointment - At 45 mins, the efficacy of the drug should be evaluated: If appropriate response is achieved, patient can be ASSISTED back to the treatment area. Apply the appropriate monitors (per State Regulations)  Commonly: pulse-oximeter, blood pressure cuff  Optional for AZ: capnometer PREOP vital signs measured & recorded on sedation record Patient should be placed in as close to a supine position as possible. Optional: supplemental oxygen via nasal mask/cannula  Oral Sedation Appointment Day of the appointment - At 45 mins, the efficacy of the drug should be evaluated: If inadequate response is observed, reassess in an additional 15-20 mins. – Signs/symptoms of appropriate response (next slide) If still inadequate, (and per permissible by State Regulations) consider: – Administer additional dose – Supplementing with N2O-O2 titrated carefully to the appropriate sedation level.  Signs & Symptoms of Appropriate Sedation PURPOSE: - reduction in anxiety, discomfort, and pain during dental procedures Intended effect: drowsiness, relaxation, slurred speech Other effects include:  Delayed reactions or response to stimuli  Some patients report tingling or heaviness of extremities (hands, feet)  Alteration in mood: smile, laugh  Decrease in BP  Some patients: amnesia (retrograde)  Oversedation – Signs & Symptoms DEFINITION Occurs when the sedative level is greater than the desired therapeutic level Common signs: Severe drowsiness (snoring), fatigue, ataxia Paradoxical reactions (rare): Excitement Hallucinations Insomnia Mood swings Rage  Oral Sedation Appointment Day of the appointment - After achieving the appropriate level of sedation: Proceed with anesthetizing the patient with local anesthetic. YES…still have to numb the patient! Sedation does not substitute local anesthesia… More importantly, inadequate LOCAL anesthesia can mimic an inadequate level of sedation  Oral Sedation Appointment - 2 Day of the appointment - Upon completion of the treatment: If administered, terminate the flow of N2O-O2, and administer 100% oxygen to the patient for a minimum of 5 mins. Collect & record post-operative vital signs on the sedation record. (sample: Malamed text or online) Patient is positioned comfortably. RECOVERY ensue and is assessed. Oral Sedation Appointment - RECOVERY If available, transfer the patient to a different room (quiet, dimly-lit) specifically dedicated for recovery. Place the patient in a comfortable, slightly reclined position. Reattach monitors to continue to assess the patient’s vital signs: BP, HR, level of consciousness. Bring in the escort to provide company for the patient. Oral Sedation Appointment - DISCHARGE Once the patient is deemed appropriate for discharge in the company of a RESPONSIBLE ADULT, the post-operative/discharge instructions will be thoroughly reviewed with the patient and escort. A copy of these instructions should be given to both. Minimum standards - any time the sedated patient stands, a TEAM MEMBER must assist, and patient discharge is only complete when the patient has been transferred via a wheelchair into the passenger or back seat of the car with the seat belt securely fastened. Oral Sedation Appointment – FOLLOW UP Later that afternoon / evening: Sign of professionalism and good patient care: Dentist should call the patient. Assess the patient’s condition, reinforce post-operative instructions. Due to the potential effects of retrograde amnesia with certain medications, this may be the first time the patient is hearing these instructions.  Drugs & Dosages - review  Which drug should I use?  How much (dosage) should I use?  Should I prescribe the drugs to the patient preoperatively, or purchase/store at the office to be dispensed for use?  Anti-anxiety drugs: Benzodiazepines Advantages  Very wide margin between therapeutic & toxic doses  Minimal to no effects on respiratory and cardiovascular depression  Minimal to no effects of hazardous drug interactions when biotransformed in the liver  Low incidence of dependence  Narrow range of contraindications: allergy, psychosis, narrow-angle glaucoma Ideal drug (refer to Table 7.3, slide coming up)  Rapid onset  Short half-life  No active metabolites  Sedative-Hypnotic drugs: Benzodiazepines Used to induce: sedation or hypnosis Spectrum of effects: – Low dosage = calming/drowsy/impairing motor skills – High dosage = hypnosis (ie. physiologic sleep) Advantage over barbiturates: minimal/no “hangover” effect  Contraindication: pregnant patients (category X) Rare side effect: Anterograde (“travelers”) amnesia – Banned in UK due to several cases of suicide Common drugs include: Midazolam (Hypnovel) Triazolam (Halcion) Classically: chloral hydrate (no longer in popular use) Reversal agent: flumazenil (Romazicon®) Drug of choice to achieve “moderate” sedation  Table 7.3 According to Malamed: Best for pre-treatment anxiolysis  Diazepam, oxazepam Best for sedation/hypnosis the night prior  Flurazepam, midazolam, triazolam I actually prefer and practice in the reverse…  What dosage? When determining the dosage to be used, consider the following factors: 1. Patient’s age, weight (BMI?) 2. Patient’s medical history 3. History of adverse reactions 4. Level of sedation desired Start by consulting with a drug reference to obtain the recommended dosages (bell-curve) Adjust accordingly based on the factors above  Example #1 Diazepam Recommended Adult dosage: 2-10 mg, 2-4 times /day Elderly/debilitated (ASA 3 or 4) patients: 2-2.5 mg, 1-2 times/day Premedication for dental treatment: 5-10mg 1 hour before bedtime & treatment Formulations available: 2, 5, 10 mg tablets OR 5mg/mL solution  Example #2 Midazolam: Recommended Adult dosage: 15 mg, 1 hr before bedtime Premedication for dental treatment: 0.25-0.5 mg/kg 1 hour before bedtime & tx 15 mg tablet 1 hour before bedtime & treatment Formulations available: 2mg/mL syrup (US) or 7.5 mg tablets (outside US)  Example #3 Triazolam: Most commonly prescribed psychoactive drug for the dental management of pre-treatment anxiety – Short half-life, no active metabolites, minimal/no hangover effect Premedication for dental treatment: 0.125 – 0.25 mg 1 hour before bedtime & tx (if non-responsive, additional 0.5 mg dose maximum) Formulations available: 0.125 or 0.25 mg tablets  Prescribe vs. Dispense If you choose to PRESCRIBE meds: Advantages: no need for storage, minimal paperwork Disadvantages: patient compliance (pickup from pharmacy, bring to appointment) If you choose to DISPENSE: Advantage: total control over patient compliance & drug availability Disadvantages:  strict legal responsibilities  storage requirements  ongoing paperwork & record keeping  Risk of theft (and associated consequences)  Drug Storage Requirements Controlled substances (drugs, medication, Rx pad) Stored in a securely locked, substantially-constructed METAL container  Safe, vault, steel cabinet  Ideally a “2-lock” system: locked cabinet in a locked room Should be limited to only a few individuals, located in an area that has minimal foot traffic (ie. locked room) If surveillance system is available, ensure the storage location is within view. Purchase of the controlled substance permit (DEA # used): sole responsibility for storage https://www.deadiversion.usdoj.gov/pubs/manuals/pract/section3.htm  Records & Paperwork Requirements Maintain accurate records - log & inventory Required by law to maintain records and update inventory every TWO years. Consider more frequent updates to ensure all drugs are current Inventory & logs must be legible: handwritten, typewritten, print form Suggestions: – keep PURCHASE records of drugs (auditing purposes) – Designate ONE staff member to manage all this paperwork Report theft or loss to local law enforcement, local Dental Board & DEA promptly. Any diversion to the controlled substances will be the responsibility of the dental practitioner https://www.deadiversion.usdoj.gov/pubs/manuals/pract/section4.htm How about nitrous oxide as an adjunct?  N2O - Advantages Rapid uptake – Compensate for the slower onset of the oral sedative – Allows for earlier delivery of local anesthesia Reduction of the gag reflex  Most important advantages Potentiate the effects of the oral sedative Option to titrate its effect – Contrast to the oral sedative: no titration available – Titration allows for safe operations, minimize chances of overdose Clark MS, Brunick AL. Handbook of nitrous oxide and oxyegen sedation. St. Louis, MO. Mosby, Inc. 2003 Complications What to look for?  Complications Oral conscious sedation is often very safe when performed within the recommended guidelines. The most common complication encountered is OVERSEDATION: Common signs/symptoms: Unresponsiveness, loss of consciousness (CNS depression) Respiratory/cardiovascular depression Treatment: activate EMS perform BLS (as needed) apply supplemental oxygen if IV access can be obtained/available: flumazenil (reversal agent) Monitoring Systems Uses / Rationale / Cost  Monitoring – What do you need? Per AZ statutes, to be granted a 1303 (oral sedation) permit, the following monitoring equipment is required: Pulse oximeter Blood pressure monitoring device (cuff) Capnograph/capnometer (optional) In addition, the following equipment/items are required: Emergency drugs – Suggest a log of each drugs and their expiration dates (ensure current) Cardiac defibrillator or automated external defibrillator (AED) Positive pressure oxygen and supplemental oxygen Stethoscope Suction equipment, including tonsillar or pharyngeal and emergency backup medical suction device Auxiliary lighting https://apps.azsos.gov/public_services/Title_04/4-11.pdf (p. 27)  Monitors – Uses/Rationale Pulse-oximeter  Measure/monitor the level of oxygen saturation in the patient’s blood.  Alerts the provider the need for intervention when the saturation level drops below a certain threshold. Blood Pressure cuff  Measure/monitor the patient’s blood pressure level at a given time  Alerts the provider the need for intervention when the blood pressure drops below a certain threshold. Capnometer/Capnograph (optional)  Measure/monitor the patient’s level of ventilation at a given time  Alerts the provider the need for intervention when the respiration rate drops below a certain threshold.  Pulse-Oximeter: Options & Cost Simple/Basic: Edan H100B pulse-oximeter Cost: $400-500 online