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• Introduction • Historical development of conscious sedation • Objectives of conscious sedation • Philosophy of conscious sedation • Indication of conscious sedation • Contraindication of conscious sedation • Pharmacology of sedative agents • Routes of drug administration • Initial assessment & treatment planning • Equipment for conscious sedation • Complication • Sedation in special circumstances
AMERICAN DENTAL SOCIETY OF ANAESTHESIOLOGY defined conscious sedation as “the production of a state of pleasant relaxation & freedom from fear & anxiety in the conscious patient through the use of drugs. “
The house of delegates of AMERICAN DENTAL ASSOCIATION (ADA) defines conscious sedation as “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 drugs & techniques that are acceptable for producing conscious sedation should have a reasonably large therapeutic index, making it unlikely that the patient will loose consciousness.
• Depressing the level of consciousness to the patient at which the patient’s only response is a reflex withdrawal from painful stimulation is well outside of the range of conscious sedation & is to be avoided.
• Conscious sedation is not to be used as a way to reduce pain during dental treatment! Local anesthesia is still required as the principle means for elimination the sedation of orofacial pain during treatment.
• However, conscious sedation may make the process of local anesthetic administration much more acceptable to the patient.
HISTORICAL DEVELOPMENT OF CONCIOUS SEDATION
• Conscious sedation techniques have been used in dentistry for over 50 years. • The ability of twenty first century dentists to provide comfortable treatment for their patients has its origin in the discovery & development of general anesthetic drugs in the 19th century. • In the USA, HORACE WELLS used nitrous oxide for the first time in 1844 & WILLIAM MORTON, administered ether for the dental extractions in October 1846. • In ENGLAND, JAMES ROBINSON, was the first to administer ether to a patient in LONDON in December 1846. • 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 1940s 1945 1960s 1966 1970s 1983 1988 1990s DEVELOPMENT “Relative Analgesia “ ( nitrous oxide / oxygen ) The Jorgensen Technique IV methohexitone (Brietal) IV diazepam (Valium) IV diazepam (Diazemuls) IV midazolam (Hypnovel) IV flumazenil (Anexate) IV propofol (Diprivan)
OBJECTIVES OF CONCIOUS SEDATION
1. The patient’s mood must be altered. The primary objective of the conscious sedative techniques is to alter the patient’s mood so that a procedure that was previously pharmacologically unacceptable now becomes readily accepted. The goal of conscious sedation is to eliminate fear & apprehension & thereby aid in control of pain reaction. Control of pain perception will be gained by judicious addition of regional anesthesia. 2. The patient must remain cooperative. Certainly when regional analgesia is being used for the control of operative pain, the cooperation of the patient is imperative. 3. The pain threshold should be elevated. Even though the dentist is relying on regional analgesia for the control of operative pain, it is advantageous to choose drugs for conscious sedation that also elevate the pain threshold at a central nervous system level. 4. All protective reflexes must remain active. In the conscious state the patient will maintain his airway clear of secretions & patent all times.
The possibility of airway obstruction by soft tissue, as occurs when consciousness is lost, is absent. 5. There should be only minor deviations in the patient’s vital signs. The patient’s physiology is not altered to the extent seen in an unconscious state. With proper drug doses & rates of administration, minor changes in vital signs within normal limits may occur because a previously fearful or apprehensive patient is now calmed. 6. There may be a degree of amnesia. Depending upon the drug & dose used, amnesia may be produced. At no time should the patient be rendered unconscious for the sake of producing amnesia.
PHILOSOPHY OF CONCIOUS SEDATION
• Without doubt most patients who need dental care may undergo treatment in a comfortable state with the use of local anesthesia alone. • But, because of fear, anxiety, & apprehension, many patients are psychologically unable to withstand dental care even though operative pain is controlled with local anesthesia.
• The baseline represents a level of awareness that is suitable for the performance of dental procedures under local anesthesia. Most of the patients present in this condition.
• Whereas others exhibit various degrees of concern, apprehension & awareness. • Those persons who are considered mildly apprehensive are amenable to management with relatively weak agents. • Moderate and very apprehensive individual require more potent medications or possibly drug combinations to place them at a level of awareness suitable for the performance of dental procedures under local anesthesia. • All the patients are not amenable to treatment in the conscious state. Some children, developmentally disabled persons, & those persons who have severe problems dealing with fears concerning dentistry are a few examples of patients who require general anesthesia.
INDICATION OF CONSCIOUS SEDATION
• Most patients requiring sedation are those with a simple genuine fear or phobia of dental treatment.
• Children can present particular problem & often require very care full handling.
• 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.
• Dentally related problems such as gagging & trismus, persistent fainting & moderately difficult or prolonged surgery.
CONTRA INDIACATION OF CONSCIOUS SEDATION
• Patients with significant cardio respiratory disease or neuromuscular weakness or wasting conditions.
• Patients with severe psychiatric disorders or mental sub normality.
• 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.
PHARMACOLOGY OF SEDATIVE AGENTS
To intelligently choose the agent that best fits the needs of patient & operator, the dentist must realize that no one agent will work for all patients.
The object of choosing the conscious – sedative agent is to select a drug or drug combination that will alter the patient’s mood to such a degree that the dental procedure can be performed under local anesthesia while the patient is in a conscious state. The dentist must, in effect, diminish fear and apprehension so that the patient is no longer psychologically threatened by dental treatment.
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
• 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 Anxiolysis Cardio respiratory stability Ease of titration Induction & recovery rate Metabolism Ease of breathing Blood gas solubility Potency (MAC) Speed of change in sedation level Systemic toxicity Environmental effects Analgesia Smooth Yes Stable Easy Rapid 0% Non – pungent Low Weak (high) Rapid None None Yes
The minimum alveolar contraction (MAC) is a value obtained experimentally which represents the potency of an inhalational agent.
• • • • 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 as well as oxygen.
It is rapidly absorbed. The rate of absorption depends on a number of factors, including the solubility of the drug in blood. Agents with low solubility produce rapid onset of sedation because the concentration of drug in blood, & therefore in the brain, rapidly equilibrates with the inspired concentration. 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. The cardiovascular effects of nitrous oxide are in significant in healthy patients.
Planes Plane I Plane II Plane III
Definition Moderate sedation & analgesia Usually obtained with concentration of 5 – 25 %N O Dissociation sedation & analgesia Usually obtained with concentration of 20 – 55 % N O Total analgesia Usually obtained with concentration of 50 – 70 % N O
N O – nitrous oxide Plane I & II are clinically useful for dental sedation. Plane III is generally considered to be too close to anesthesia to be safe in the dental outpatient setting.
The low solubility of nitrous oxide in blood & tissues results in rapid out flow of nitrous oxide across the alveolar membrane when the incoming gas flow is stopped. This reduces the percentage of alveolar oxygen available for. This phenomenon – “diffusion hypoxia” – may be counteracted by giving 100 % oxygen for 2 minutes at the end of the procedure.
PROPERTIES: Induction characteristics Anxiolysis Cardio respiratory stability Ease of titration Induction & recovery rate Metabolism Ease of breathing Blood gas solubility Potency (MAC) Speed of change in sedation level Systemic toxicity Environmental effects Analgesia SUPPLIED AS: Smooth Yes Stable Easy Rapid < 1% Non – pungent Low ( 0.47) Weak (105 %) Rapid Yes (prolong use) Yes Yes
is supplied in a blue cylinder containing both a 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).
ADVANTAGES: • • • • • • Ability to titrate Ability to reverse Controlled duration 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 bane marrow depression • Increase in the rate of miscarriage among women dentists & dental nurses who are exposed to nitrous oxide for prolong period of time. • • • •
• It is a fluorinated derivative of methyl isopropyl ether which was first synthesized in the early 1970s. • It 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 Anxiolysis Cardio respiratory stability Ease of titration Induction & recovery rate Metabolism Ease of breathing Blood gas solubility Potency (MAC) Speed of change in sedation level Systemic toxicity Environmental effects Analgesia Smooth Yes Stable Easy Rapid 5% Non – pungent Low ( 0.6) High (2 %) Fairly rapid Not known Minimal No
A specially calibrated vaporizer is required in order to titrate low concentrations of sevoflurane.
Properties of an ideal intravenous agent:
Injection characteristics Anxiolysis Cardio respiratory stability Ease of titration Induction & recovery rate Metabolism Analgesia Potency Reversibility Speed of change in sedation level Systemic toxicity Storage / shelf life Painless Yes Stable Easy Rapid 0% Yes Weak Yes Rapid None Stable / long
The benzodiazepine group of drugs has a number of desirable pharmacodynamic properties which make these agents useful for conscious sedation. This includes: • • • • • Anxiolysis Sedation Muscle relaxation Anterograde amnesia Anticonvulsant action
All benzodiazepines have a common core structure with individual differences which determine their solubility and precise actions.
MECHANISM OF ACTION:
It acts throughout the CNS. Specific benzodiazepine receptors are located on nerve cells within the brain. All benzodiazepine molecules have a common core shape, which enables them to attach to these receptors. The effect o attaching benzodiazepines to cell membrane receptors to alter an existing physiological filter.
The normal passage of information from the peripheral senses to the brain is filtered by the GABA (gamma amino butyric acid) system. GABA is an inhibitory neurotransmitter which is released from sensory nerve endings as a result of nerve stimuli passing from neuron to neuron. When released, GABA attaches to receptor on the cell membrane of the postsynaptic neuron. This stabilizes the neuron by increasing the threshold for firing. In this way, the number of sensory messages perceived by the brain is reduced. Benzodiazepine receptors are located on the cell membrane close to GABA receptors. The effect of having benzodiazepine in place on a receptor is to prolong the effect of
GABA. This further reduces the number of stimuli reaching the higher centers & produces pharmacological sedation, anxiolysis, amnesia, muscle relaxation and anticonvulsant effects. Benzodiazepines must cross the blood brain barrier to reach their target receptors.
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