12/2/20

Intravenous Sedation
Dr Saleh Alkadi
BDS, MFD RCSI, NBDE, D.Ch.Dent, FFD RCSI (OS), JB(OMFS)

Intravenous sedation

• The technique of choice for most adult dental

patients requiring conscious sedation
• Produces a predictable and reliable
pharmacological effect
• More potent and quicker-acting than inhalation
or oral sedation

1
 12/2/20

Pathway of IV sedative
• Venous blood returns from the body to right side of heart

• Pumped to the lungs via the pulmonary artery

• Returns oxygenated to left side of heart

• Pumped into general circulation via aorta

• Cerebral circulation to brain

Pharmacokinetics

2
 12/2/20

Indications for IV sedation

Moderate to severe dental anxiety

Traumatic surgical procedures

Gag reflex and swallow reflex are present

Mild medical conditions which may be aggravated by the stress of dental

treatment, for example mild hypertension or asthma
Mild intellectual or physical disability, for example mild learning disability, cerebral
palsy.

Contraindications for IV sedation

History of allergy to benzodiazepines

Impaired renal or hepatic systems
Pregnancy and breast feeding
Severe psychiatric disease
Drug dependency.

3
 12/2/20

Other
Considerations

Advantages and Disadvantages of IV Sedation

4
 12/2/20

Drugs for IV sedation

• Benzodiazepine (diazepam, midazolam)
• Barbiturate
• Propofol
• Narcotic (opioids)
• Dissociative agents:
oPhencyclidines (ketamine)
oEtomidate (Amidate)

Benzodiazepine

• Modern IV sedation techniques depend almost

exclusively on the benzodiazepines
• Both midazolam and diazepam are suitable IV
sedatives
• The pharmacokinetics of midazolam make this
the preferred choice for dental sedation.

10

5
 12/2/20

Diazepam for IV sedation

• The 1st benzodiazepine to be used in IV sedation practice
• Almost insoluble in water
• Long elimination half-life ( 43 hours +/-13)
• Metabolised in the liver and eliminated via the kidneys
• Active metabolite can cause rebound sedation up to 72
hours after the initial administration of diazepam
• Presented in a 2 ml ampoule in a concentration of 5
mg/ml
• Standard dose lies in the range 0.1–0.2 mg/kg.

11

Midazolam (Hypnovel)
for IV sedation
• Water soluble
• Elimination half-life of 1.9 hours
• 2.5 times as potent as diazepam
• Has more predictable amnesic
properties, than diazepam.
• Rapidly metabolised in the liver, which
produces an active metabolite with
short half-life
• Midazolam is presented in different
concentrations.
• Most patients require a dose usually in
the range of 0.07–0.1 mg/kg.

12

6
 12/2/20

Clinical Effects of Sedation

with IV Benzodiazepines
• Conscious sedation with acute detachment (lack of
awareness of one’s surroundings) for a period of 20–30
minutes after administration,
• Followed by a period of relaxation which may last for a
further hour or more
• Anterograde amnesia, that is, loss of memory following
administration of the drug
• Muscle relaxation (useful for those with cerebral palsy)
• Anticonvulsant action
• Slight cardiovascular and respiratory depression.
• Produce NO any clinically useful analgesia

13

Advantages of Intravenous Benzodiazepine

• Reasonably wide margin of safety between the end
point of sedation and loss of consciousness or
anaesthesia (although it is easy to induce sleep
with moderate over-dosage)
• A satisfactory level of sedation is attained
pharmacologically rather than psychologically
• Recovery occurs within a reasonable period and the
patient can usually be discharged home less than
two hours following completion of treatment.

14

7
 12/2/20

Disadvantages of Intravenous Benzodiazepine

• Respiratory depression
• Cardiovascular depression
• Over-sedation in older people and children
• Tolerance
• Sexual fantasy
• Disinhibition

15

Flumazenil (Benzodiazepine Antagonist)

• The first drug to effectively and completely reverse the effects of almost all
benzodiazepines.
• A true benzodiazepine but it has virtually no intrinsic therapeutic activity
• Has a greater affinity for the benzodiazepine receptor than virtually all the
known active drugs (effective antagonist)
• Reverse (at least on a temporary basis) the sedative, cardiovascular and
respiratory depressant effects
• Has a shorter elimination half-life (53 minutes, +/−13 minutes) than the
active benzodiazepines
• Used in emergency situations and as a reversal to hasten recovery
• Presented in 5 ml ampoules (500 mcg/5ml)

16

8
 12/2/20

Barbiturates
• Act as nonselective CNS depressants
• Produce a wide spectrum of effects, from mild
sedation to total anesthesia.
• Also has anxiolytic and anticonvulsant properties
• Classified according to their duration of activity
• Today, they are rarely, if ever, indicated for use in
moderate sedation
• E.g.: Pentobarbital or Secobarbital

17

Propofol (Diprivan)
• A potent intravenous hypnotic agent (enhancing the GABA)
• Used for the induction and maintenance of anaesthesia and for sedation in ICU.
• The use of propofol for IV moderate sedation by non-general anesthesia–trained
dentists is not recommended.
• Antiemetic properties
• Decreases intraocular pressure as well as intracranial pressure
• Can cause a decrease in respiratory rate and apnea
• Causes bronchodilation in patients with COPD
• Has a direct myocardial depression and decreased systemic vascular
resistance (profound hypotension)
• Advantage of undergoing rapid elimination and recovery (30 minutes)
• Presented as an aqueous white emulsion at a concentration of 10 mg/ml in 20 ml
18

9
 12/2/20

Opioids
• Have pain attenuation and some sedation effects
• Used in multidrug IV sedation
o Meperidine
o Morphine
o Fentanyl
o Sufentanil
o Alfentanil
o Remifentanil

• Naloxone (Narcan) is an opioid antagonist that can reverse the respiratory

depression, urinary retention, rigidity, and nausea and vomiting associated
with opioids.

19

Phencyclidines (Ketamine)
• Produces amnesia and analgesia
• Combination of ketamine with a benzodiazepine prolongs
the effect of ketamine
• Can cause increased heart rate, cardiac output, and blood
pressure
• Causes bronchial smooth muscle relaxation
• Also produces an associated increased salivation that can
cause upper airway obstruction leading to a laryngospasm
• Ketamine increases cerebral blood flow and intracranial
pressure.

20

10
 12/2/20

Etomidate (Amidate)
• Used for the induction of GA and sedation
• Has a rapid onset of action and a safe cardiovascular
risk profile, and therefore is less likely to cause a more
significant reduction in blood pressure than other
induction agents
• Suppression of ventilation is minimal, histamine
liberation is inhibited, and it can be used safely in
patients with myocardial and cerebral ischemia
• Etomidate-related adrenal insufficiency.

21

Equipment required for the administration of IV sedation agents

22

11
 12/2/20

Cannulation

23

24

12
 12/2/20

Sedation end point

• The sedation end point is reached when several specific signs of
sedation are apparent:
1) Slurring and slowing of speech
2) Relaxed demeanour
3) Delayed response to commands
4) Willingness to undergo treatment
5) Positive Eve’s sign
6) Verill’s sign.

25

Eve’s sign

26

13
 12/2/20

Verill’s sign

27

Clinical and Electromechanical Monitoring

• Clinical Monitoring: • Electromechanical Monitoring:
o Patency of the patient’s airway oPulse oximetry
o Pattern of respiration oBlood pressure
o Pulse
o Skin colour
o Level of consciousness

28

14
 12/2/20

Pulse oximetry

29

Blood pressure

30

15
 12/2/20

Capnography

31

ECG

32

16
 12/2/20

33

Nasal O2

34

17
 12/2/20

Recovery

• Occurs by two processes :

o The first is the redistribution of the sedation
agent from the CNS into the body fat.
o The second process involves the uptake and
metabolism of the sedation agent in the liver
and elimination via the kidneys.

35

Discharge criteria

• Ability to walk in a straight line unassisted

• Speech no longer slurred
• Oxygen saturation back to baseline
• Blood pressure restored to near baseline
• Presence of suitable escort.

36

18
 12/2/20

Post-operative care
instructions
• Rest quietly at home for the rest of the day
• For the next 24 hours, refrain from:
o Driving
o Drinking alcohol
o Operating machinery or domestic appliances
o Signing legal documents
o Making Internet transactions.

37

Intranasal sedation
• A form of transmucosal sedation
• Become more popular in recent years, especially in special
care dentistry for patients with challenging behaviour.
• Also indicated in patients with severe needle phobia who
will not allow placement of a cannula for intravenous
sedation.
• Not titratable
• Midazolam used for intranasal administration is 40 mg/ml
and the initial dose is 10 mg for adult patients.

38

19
 12/2/20

39

Questions

40

20