Application Of INTRAVENOUS SEDATION For Oral and Maxillofacial Surgery

SAAD A. SHETA, MD
Associate Professor, Anesthesia MDS Department Dental College KSU

Sedation

Complications Emergency

IV Sedation

Office Based

Guidelines

SEDATION

SEDATION

It is a technique where one or more drugs are used to Depress the Central Nervous System of a patient thus reducing the awareness of the patient to his surrounding

According to the degree of CNS depression:

Conscious Sedation Deep Sedation General Anesthesia

Conscious Sedation

It is a controlled, pharmacologically induced, minimally depressed level of consciousness that retains the patients ability to maintain a patent airway independently and continuously and respond appropriately to physical and/or verbal command

Deep Sedation

It is a controlled, pharmacologically induced state of depressed level of consciousness. from which the patient is consciousness. not easily aroused and which may be accompanied by a partial loss of protective reflexes, including the ability to reflexes, maintain a patent airway independently and/or respond purposefully to physical stimulation or verbal commands

Sedation (levels)
Level 1: Mild sedation Level 2: Interactive Level 3: Non-Interactive/Arousable with moderate stimulus

(Conscious Sedation) Level 4: Non-Interactive/ Non-Arousable except with intense stimuli (Deep Sedation) Level 5: G A (General Anesthesia)

Cons. Sedation
Minimally Depressed Consciousness

Deep Sedation
Deeply
depressed consciousness

 Anxiolysis  Interactive  Non interactive/arousable

 Sleeplike state  Non-Interactive  Non- arousable (tense stimulation)

Cons. Sedation

Deep Sedation

 Airway is maintained  Protective reflexes are intact  Responses to command are intact

 Inability to maintain airway  Partial loss of reflexes  Difficult to respond to command

Fundamental Concepts
 It is easy to drift from one state to another

 Patient state is considered in terms of the level of consciousness rather than the technique involved

 Sedation techniques are not pain-control techniques

Main Anesthetic Concerns

Rapid Recovery & Minimal Postoperative Morbidity Sedation will be provided to the patient and he/she allowed home in the same day of surgery

Remote locations Procedures are commonly performed in a facility away from the proper hospital setting

Indications
 Fearful Patients  Stressful Procedures

 Behaviorally Challenged Patients  Medically Challenged  Gagging  Local Anesthesia Problems  Young Children

Fearful Patients

 1/2 of population is fearful

(USA population is 270 million)

 10% -15% sufficient fear  23 million preferred sedation or anaesthesia  One third received such care

Stressful Procedure

 3 rd Molar extractions
(5 million sedation and anesthesia / year USA)

 Interosseous implants  Complex peridontal surgery

Gagging and Local Anesthesia Problems

 One tenth of dentists reports LA failure /week  LA resistance  Stress reactions:

2.5% of adverse systemic responses (1% allergic)

Behaviorally Challenged Patients

 10 million children in the USA  1 million adults are severely retarded  Elderly

Medically Challenged
 They need Monitored Anesthesia care (MAC)

INTRAVENOUS SEDATION

Common IV Agents Employed

Benzodiazepines
  Diazepam (Valium) Midazolam (Dormicum) 

Benzodiazepine antagonist
Flumazenil (Aniexate)

Narcotics
   Pethedine Fentanyl Remifentanil 

Narcotic Antagonists
Naloxone (Narcan)

Intravenous Anesthetics
  Ketamine (ketalar) Propofol (Diprivan)

Midazolam
 Pharmacodynamics of benzodiazepines

Anxiolysis

 Sedative  Hypnotic  anticonvulsant  Anterograde amnesia

 Highly lipophilic diazepam)

(twice

as

potent

as

 Clinically inactive metabolites (recovery in 2 hrs)  Water soluble less)

(Thrombophlebitis

is

 Short acting diazepam)

(10 times less than

 Reversal (Flumazenil)

agent

is

available

Sedation Technique with Midazolam

Initially 2mg waits for 2 min Further increments are then injected, 1 mg/1 min until drooping of the eyelids is observed Local anaesthesia

Problems

 dose-related risk of apnea, which is believed to be influenced by the rapidity with which the drug is administered

 Hypotension (narcotics)

Benzodiazepine antagonist Flumazenil (Aniexate)

 competitive, high affinity interaction with benzodiazepine receptors  reversing the sedative effects but not necessarily the amnesic or anxiolytic qualities  Initial dose should be 0.2 mg given over 15 seconds waiting 45 sec, another dose of 0.2 mg should be administered and repeated at 60 second intervals to a maximum total dose of 1 mg

 Indication  Unintentional iatrogenic overdose  Extreme sensitivity  Paradoxical reactions

 Side Effects  Withdrawal symptoms  Induced seizure activity  Resedation

Propofol

 Mood-altering, euphorogenic, capability of producing easily controllable level of sedation  Ideal for ambulatory setting  Predictable recovery after single and repeated doses)

Problems:

 Low therapeutic margin  Talking  Referred to as anaesthetic agents and at present are not recommended for sedation by surgeons (dental practitioners)

Remifentanil
 Structurally unique, ester linked  Rapid hydrolysis by non-specific esterases  Inactive metabolites  highly predictable onset and offset of action
Granzberg S, Pape RA, Beck FM. Remifentanil for use during conscious sedation in outpatient oral surgery
J Oral Maxillofac Surg 2002; 60(3): 244-50

INTRVENOUS SEDATION

Broadly categorized into:  Sedationist Controlled

 Patient Controlled  Computer Controlled

Sedationist Controlled Sedation

 Either one drug or combinations of iv drugs  Commonest combination Benzodiazepines & opioid Propofol & opioid (Bradycardia!)  Increments Verrils sign prior to vs. end of surgery

Patient Controlled Sedation

Similar to Patient Controlled Analgesia (PCA)

 Pain control by local anesthesia

 Propofol better than midazolam

Rodrigo MRC, Chowk KC Patient controlled sedation: a comparison of sedation prior to and sedation till end of surgery
Australian Dent J 1996;41: 159-63

VL Oei-Lim, CJ Kalkman, PC Makkes and WG Ooms Patient-controlled versus anesthesiologist-controlled conscious sedation with propofol for dental treatment in anxious patients
Anesthesia & Analgesia 1998 ;86:967-72

Computer (Target) Controlled Sedation

Target Controlled Pump

Infusion

Computer (Target) Controlled Sedation

 A preset pharmacokinetic model (any drug)

 Predicted blood level (target controlled concentration) Propofol : adequate sedation (infusion rate=25-100 ug.kg1.min-1) based on estimation of target plasma concentration for sedation (0.5-1.5ug.ml-1)

COMPLICATIONS

Respiratory Complications

 Airway Obstruction  Respiratory Depression

Respiratory Complications
Airway Obstruction Causes  Tongue  Blood, debris  Laryngeal spasm  A-W Obstruction  Hypoxia Respiratory Depression  Narcotics  Over-sedation

Clinical Picture

 Hypoventilation  Hypercapnia  Hypoxia  Ventilation  Reversal Agents

Management

 Patent airway  Oxygenation

Airway Obstruction
Most common cause: tongue and/or epiglottis

Open the Airway Position

Jaw thrust

Head tiltchin lift

Open the Airway Oropharyngeal Airway

Open the Airway Nasopharyngeal Airway

Open the Airway Endotracheal Intubation Aligning Axes of the Airway

Open the Airway Endotracheal Intubation Laryngoscopes

ETT, Stylet, and Syringe unassembled

Glottis visualized through laryngoscopy

Open the Airway Endotracheal Intubation Visualization of the Cord

Laryngeal Mask Airway

Open the Airway Laryngeal Mask Airway (LMA)

Oxygenation
Adjunct Devices

Ventilation
Bag-Mask Ventilation
 Key ventilation volume: enough to produce obvious chest rise

1 Person difficult, less effective

2 Persons easier, more effective

Cardiovascular Complications

 Hypotension  Dysrhythmia

 Hypotension

Oversedation Carotid sinus compression

 Dysrhythmias
Aetiology

(Tachy-arrhythmias)
(Tooth extraction)

 High preoperative catecholamines  Airway obstruction & hypoxia  Local anesthesia with vasopressors Significance  Controversial  Significant with unexpected cardiac disease (viral myocarditis)

Miscellaneous

 Nasal Trauma, Epistaxis  Pulmonary Aspiration  Continued Bleeding  Post operative Nausea & vomiting  Post operative Pain & swelling

Guidelines for Sedation

ASA
American Society of Anesthesiologists Task Force on Sedation and Analgesia by non-anesthesiologists: Practice guidelines for sedation and analgesia by non-anesthesiologists

Anesthesiology 1996; 84:459-471

AAPD
Guidelines for the elective use of conscious sedation, deep sedation, and general anesthesia in pediatric patients
Pediatr Dent 1985; 7:334

Patient Selection
ASA grade I & II

Contraindications
         Serious cardiopulmonary diseases, COPD Diabetes or other endocrinological diseases Neuromuscular disorders Coagulopathies & Hemoglobinopathies Marked oro-facial swelling (edema& trismus) Potential difficult airways Extreme obesity Drugs: MAOIs , Anticoagulant Not fasting

Patient Evaluation Goals:

 Awareness of Pre-existing Medical Conditions  Treatment Protocol

   

Timing Of Appointment Prophylaxis against SBE Conscious Sedation Hospital arrangement

Patient Evaluation
 Relevant aspects of the patients Medical History including:  abnormalities of the major organ systems  previous adverse experience with sedation, as well as general anesthesia  Current medications and drug allergies  Time and nature of last oral intake  History of tobacco, alcohol, or substance use or abuse  Focused Physical Examination including auscultation of the heart and lungs and evaluation of the airway

Pre-procedure Laboratory Testing should be guided by the patients underlying medical condition

Pre-procedure Preparation
 Patient Counseling Benefits Risks Limitations possible alternatives  Consent

 Pre-procedure Fasting

Patient Monitoring
 Sedation
 Level of consciousness  Clinical Observation (Observe at least one extremity )        Pulse Precordial stethoscope ECG NIBP Pulse Oximetry Impedance Plethysmography Recording of vital sings at a minimum of 5 minutes

Prolonged Sedation
 Continuous temperature monitoring  Capnography

Pulse Oximeter

Combined devices check pulse oximetry, ETCO2 blood pressure, respiratory rate, and temperature

pulse,

Recording of Monitored Parameters

Recording of vital signs and respiratory variables:

    

Before initiating sedation After administration of medications At regular intervals On initiation of recovery Immediately before discharge

Availability of Staff Person Dedicated Solely to Patient Monitoring and Safety

Anesthesia Team Concept

 A designated individual, performing the procedure

other

than

the

practitioner

 May assist with minor, interruptible tasks

Intravenous Access

 Intravenous medications for sedation\analgesia

 In all instances, an individual with the skills to establish intravenous access should be immediately available

 Reversal Agents

Use of Supplemental Oxygen

Titration of Sedative\Analgesic Medications to Achieve the Desired Effect

Consultation with appropriate specialists

PREPARATION FOR EMERGENCIES

 Personal Preparation  Staff Preparation  Office Preparation

Training of Personnel (Practitioner)

 Clinical Pharmacology Medical emergencies that occur as a direct result of medications for techniques  Anticipate & be prepared to deal with the Most likely Medical Emergencies syncope, hyperventilation, seizures, hypoglycemia, postural hypotension, asthma, allergic reactions and airway obstruction  One qualified individual , capable of establishing a patient airway and maintaining ventilation and oxygenation (Basic life support)  Advanced cardiac life support

Staff Preparation (Office Personnel)

 Certified in basic CPR (ALL Staff)  Pre-assigned role in case of an emergency  Mock medical emergency drill

Office Preparation

 Equipment  Emergency Equipment  Emergency Drugs  Backup Medical Assistance

Equipment

 Dental Chair  Anesthetic Equipment  Resuscitation Equipment

Up to the standards of In-Patient GA

Dental Chair
 Adjustable: ( horizontal /Head down)  Manual release  Adjustable head rest  Hospital out-patient: operating table

Anesthesia Equipment
 Continuous machine flow anesthesia

 Cylinder, flow meter, Bag-ValveMask

 Quantiflex (Relative Analgesia)

Emergency Equipment

Emergency Equipment
 Oxygen Source  Airway Adjuncts : Airways, Masks and Nasal prongs  Bag-valve- mask  High Volume Suction Device  Others: Crash Cart

Oxygen (Central)

Oxygen (Cylinders)
An oxygen source capable of delivering greater than 90% oxygen of flows in excess of 5 liters/minute for a minimum of 1 hour must be available

E cylinder if the minimum size required

Airway Adjuncts

If breathing adequately spontaneously

Bag-valve-Mask

If Artificial ventilation necessary

built-in colorimetric ETCO2 detector

Crash Cart

Crash Cart
 Intravenous Line: Cannulae Syringes Needles  Airway Adjuncts  Endotracheal Intubation  Cricothyrotomy  Emergency Drugs

Intravenous Line: Cannulae, Syringes, Needles

Endotracheal Intubation Equipment

Cricothyrotomy Equipment

Miscellaneous

Emergency Drugs

       

ACLS drugs Antagonists Anticonvulsants Drugs to treat Allergy Steroids Antihypoglycemic Vasopressors Analgesics

HELP
Backup Medical Assistance

Future of OBDS

Where?

By whom?

How ?

Where?

Surgicenter Versus Office

 Certification  Anesthesiologists satisfaction  Patient Safety

By Whom?

Anesthesia Provider

 Oral and maxillofacial surgeons  Operator anesthetist  Dentist anesthesiologists

ASA opposition

How?
Advances in Pharmacology and technology Development of drugs

 Drugs  Monitoring  Drug Delivery system

Drugs

 Ambulatory suitable drugs (midazolam, propofol, sevoflurane, remifentanil,)

 Efficient sedation and analgesia without respiratory depression

Monitoring : Capnography

 Respiratory monitor effective 100% for apneic event  Sampling line attached to the nasal mask sample dilution (underestimation)

Monitoring : Bispectral Index BIS

Monitoring : BIS
 Strong correlation with subjective assessment of sedation  Titrate level of sedation to values of 70-80

 Therefore, less drugs are used to maintain the desired level

Drug Delivery System

Coupling of monitoring devices and automated data recording and drug delivery system

FUTURE OFFICE BASED DENTAL SEDATION

 Acceptance of ambulatory anesthesia has grown dramatically since 1980

OUTPATIENT BASIS In 1979 In 1987 Recent Trends Less than 20% 45% 70% Office setting 1/8 Free-standing surgicenter 1/4

FUTURE OFFICE BASED DENTAL SEDATION

Primum Non Curarum

(First not to Harm)

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