Sedation – DentEpic

Sedation	Response to verbal commands	Cognitive function and coordination	Ventilatory function and cardiovascular function
Minimal sedation	A drug-induced state during which patients respond normally to verbal commands	May be impaired	Unaffected
Moderate sedation	A drug-induced depression of consciousness during which patients respond purposefully to verbal commands	For older patients, this level of sedation implies an interactive state; for younger patients, age-appropriate behavior (e.g., crying) occurs and is expected	No intervention is required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained
Deep sedation	A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully after repeated verbal or painful stimulation	Noninteractive and does not respond purposefully to physical stimulation or verbal command	Ventilatory function impaired. Require assistance in maintaining a patent airway. May be partial or complete loss of protective airway reﬂexes Cardiovascular function may also be impaired

Deep sedation and general anesthesia = conditions of patients characterized by an incomplete, partial or total loss of the ability to independently and continuously maintain a patent airway, cardiovascular function may also be impaired

Occasionally the sedated patient will drift into normal sleep. When this occurs, it becomes the practitioner’s responsibility to be assured that what is being observed is a normal sleep state by frequently arousing the patient

Goals of sedation

To guard the patient’s safety and welfare
To minimize physical discomfort and pain
To control anxiety, minimize psychological trauma, maximize the potential for amnesia
To control behavior or movement so as to allow the safe completion of the procedure
To return the patient to a physiologic state in which safe discharge is possible

Anatomic and physiologic differences

- Narrow nasal passages and glottis
- Hypertrophic tonsils and adenoids : tonsillar tissue that occupies >50% of pharyngeal space increases risk for respiratory obstruction

Enlarged tongue

Greater secretions

Reduced tolerance to respiratory obstruction (sudden apnea)
Smaller thorax, less expansion capability, less functional reserve : more prone to rapid desaturation on obstruction or respiratory depression
Faster heart rate, lower blood pressure : more susceptible to bradycardia, decreased cardiac output, and hypotension
Compensatory mechanisms to maintain adequate blood pressure not as well developed in children
More variable effect and duration of action of drugs
Better peripheral perfusion, more rapid onset of intramuscular administered drug

Instruction to parents

Before sedation

Food

No milk or solid foods 6 hours before the sedation appointment
Clear liquids such as water, clear juices, gelatin, Popsicles, or broth, may be given up to 3 hours before the appointment
Let everyone in the home know the above information, because siblings or others living in the home often unknowingly feed the child

Activity

Plan the child’s sleep and awakening times to encourage the usual amount of sleep the day before the sedation appointment
Arrive on time
The legal guardian must accompany the child to the sedation appointment
A second responsible adult must join to enables one adult to drive the car while the second adult focuses attention on your child after the treatment is completed. The child should be carefully secured in a car seat belt during transportation
Make sure the child uses the restroom before the sedation

After sedation

Activity

The child may take a long nap. He/she may sleep from 3 to 8 hours and may be drowsy and irritable for up to 24 hours after sedation. When the child is asleep, parents should be able to awaken him/her easily
Child may be unsteady when walking or crawling and will need support to protect him/her from injury. Adult must be with the child at all times until the child has returned to his/her usual state of alertness and coordination
The child should not perform any potentially dangerous activities, such as riding a bike, playing outside, handling sharp objects, working with tools, or climbing stairs until he/she is back to his/her usual alertness and coordination for at least 1 hour
Closely supervise any activity for the remainder of the day

Food

Begin by giving clear liquids such as clear juices, water, gelatin, Popsicles, or broth. If your child does not vomit after 30 minutes, you may continue with solid foods.

Call the doctor if

Unable to arouse the child
Unable to eat or drink
Experience vomiting or pain
Develops a rash

Discharge criteria

Cardiovascular function is satisfactory and stable
Airway patency is uncompromised and satisfactory
Patient is easily arousable and protective reﬂexes are intact
State of hydration is adequate
Patient can talk, if applicable
Patient can sit unaided, if applicable
Patient can ambulate, if applicable, with minimal assistance
If the child is very young or disabled, incapable of the usually expected responses, the presedation level of responsiveness or the level as close as possible for that child has been achieved
Responsible individual is available

Techniques of sedation

Nitrous oxide and oxygen sedation	Most frequently used sedative agent Objectives Reducing or eliminate anxiety Reducing untoward movement and reaction to dental treatment Enhancing communication and patient cooperation Raising the pain threshold Increase tolerance for longer appointments Aiding in treatment of the mentally/physically disabled or medically compromised patient Reducing gagging Potentiating the effect of sedatives Disadvantages Lack of potency Dependence on psychological reassurance Interference of the nasal hood with injection to anterior maxillary region Need for patient to be able to breathe through the nose Nitrous oxide pollution and potential occupational exposure health hazards Pharmacokinetics Very rapid onset and recovery time No biotransformation, rapidly excreted by lungs Diffusion hypoxia may occur (to minimize this, oxygenated 3-5 minutes after sedation) Pharmacodynamics Nonspecific CNS depression 30-50% NO : relaxed, somnolent patient >60% NO : discoordination, ataxia, gliddiness, increases sleepiness (concentration should not >50%) Should be avoided in patients who rely significantly on hypoxia-drive ventilation Decreased cardiac output, increases peripheral vascular resistance (consideration only in patient with severe cardiac disease) Can easily be titrated up and down Adverse effects and toxicity Excellent safety record, few adverse effects Nausea, vomiting NO entrapped in gas-filled spaces (should be avoided in patients with acute otitis media) Contraindicated in severe behavioural problems, emotional illness, uncooperativeness, maxillofacial deformities that prevent nasal hood placement Technique Thorough inspection of equipment Introduce mask with explanation Carefully place the mask over the nose Employ traditional behavior guidance techniques Tighten delivery tube behind the chair back 100% oxygen delivered for 1-2 minutes at flow rate 4-6L/min Slowly increase the concentration at increments of 10-20% to achieve desired level Encourage patient to breathe through the nose with mouth closed Explain sensation as they begin to feel so When eye will take a distant gaze with saggling eyelids / floating feeling, LA may be given Monitoring Responsiveness, color, assessment of respiratory rate and rhythm
Oral sedation	Most variable (dependent on absorption through GI mucosa) Vary in peak and consistency of effect Difficult reversal of unwanted effect Cannot titrate the drug Prolonged recovery time (slowly metabolized) Technique Select and calculate proper dose of medication Keep patient in area of office for continuous monitoring Desired effect after 30-60 minutes Transfer patient to the chair Arms, legs, and midbody should be secured; chest and diaphragm must be not restrained May start NO and O2 at this time If patient not adequately sedated, attempt should be aborted (given another appointment : altered dose or technique / deep sedation / GA) Increments of medication should not be given (overdose risk) Monitor patient to ensure responsiveness Full oral and written instruction on postsedation care
Intramuscular sedation	Not preferred over oral route especially in younger age group Prolonged time required to reach peak effect Variability and unpredictability in onset and effect Total lack of reversibility except narcotics and benzodiazepines Greater opportunity of idiosyncratic reaction
Submucosal sedation	Best if they are placed subperiosteally Usually site of injection : buccal vestibule in the area of maxillary primary molar or canine teeth Suitable for whom quick administration and onset is desirable This technique has fallen out of favor in recent years
Intravenous sedation	Easiest, most efficient, safest next to sedation by inhalation More suitable for apprehensive preteen and adolescent patient Complication : hematoma at site of venipuncture

Intraoperative monitoring

Assess oxygenation, ventilation, circulation
Evaluate the state of consciousness frequently by verbal communication
Assess perfusion from patient’s appearance : oral mucosa, nail beds, complexion of skin
Continuously monitor heart and respiratory rates, quality of heart and breath sounds, excursion of chest
Monitor blood pressure for deeper levels of sedation

Postoperative monitoring

Stable vital signs before discharged
Able to remain awake for >20 minutes
Level of awareness close to usual state for very young or disabled patient