Anesthesia & Sedation in Dentistry

7/27/2019 Anesthesia & Sedation in Dentistry

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Dental Anxiety: Fear of dental treatment or dentalinstruments.

Dental phobia: Special kind of fear that is out ofproportion to demands of the situation that doesntrespond to is apparently beyond a voluntary control,and leads to avoidance of dental treatment.


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Dental Anxiety: Fear of dental treatment or dentalinstruments.

Dental phobia: Special kind of fear that is out ofproportion to demands of the situation that doesntrespond to is apparently beyond a voluntary control,and leads to avoidance of dental treatment.


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Fear-------- Fainting

Anxiety--------palpitation ( tachycardia,

arrhythmia)Hypertension


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Stress responseDefinition:

It is the name given to the hormonal andmetabolic changes which follow injury or trauma.

This is part of the systemic reaction to injurywhich encompasses a wide range ofendocrinological, immunological and

hematological effects. Thus it is a Group of reactions with functional and

protective effects.


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Activation of the stress response The endocrine response is activated by afferent

neuronal impulses from the site of injury.

These travel along sensory nerve roots through thedorsal root of the spinal cord, up the spinal cord to themedulla to activate the hypothalamus.


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StimuliStress and fear. Induction ofanesthesia Surgical incision


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The stressresponse to surgery is characterized by increased secretion of pituitary

hormones and activation of the sympathetic nervoussystem


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Stages *Immediate circulatory adjustment stage: *Late

metabolic changes stage


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Immediate circulatory adjustment

stage: Increase sympathetic discharge from the adrenal

medulla and nerve endings-> Adrenaline andnoradrenaline- Vasoconstriction of the splanchiccutanuous vessels -> keep perfusion of the vital organs.


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Sympathoadrenalresponse

Hypothalamic activation of the sympathetic autonomic nervous system--increased secretion of catecholamines from the adrenal medullaand release of norepinephrine from presynaptic nerve terminals.Norepinephrine is primarily a neurotransmitter, but there is somespillover of norepinephrine released from nerve terminals into thecirculation. The increased sympathetic activity results in the wellrecognized cardiovascular effects of tachycardia and hypertension. Inaddition, the function of certain visceral organs, including the liver,pancreas and kidney, is modified directly by efferent sympatheticstimulation and/or circulating catecholamines.


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Pituitary Gland
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Immediate circulatory adjustment stage Increase sympathetic discharge from: * Adrenal

medulla * Nerve endings----------- adren. & noradren.


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Late metabolic changes stage Mediated by both: autonomic & hormonal responses

to adrenal cortical hormones. * The catabolic phase:(48 hours) - Oliguria - Break down of bodyprotein - k+ loss - Na+ retention

*The anabolic phase: Restoration ofbody protein


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Posterior pituitary

The posterior pituitary produces arginine vasopressinwhich has a major role as an antidiuretic hormone.


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Anterior pituitary Anterior pituitary hormone secretion is stimulated by

hypothalamic releasing factors. The pituitary synthesizes-corticotrophin or adrenocorticotrophic hormone (ACTH).

- Growth hormone -prolactin aresecreted in increased amounts from the pituitary inresponse to a surgical stimulus.Concentrations of the other anterior pituitary hormones, -

thyroid-stimulating hormone (TSH), -follicle-stimulating hormone (FSH) -luteinizing hormone (LH) donot change markedly during surgery


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Corticotrophin

Corticotrophin (ACTH) is a 39 amino acid peptide,produced in the pituitary. ACTHstimulates the adrenal cortical secretion ofglucocorticoids so that circulating concentrations ofcortisol are increased.


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Cortisol

Cortisol secretion from the adrenal cortex increasesrapidly following the start of surgery, as a result ofstimulation by ACTH. From baseline values of around

400 nmol litre1, cortisol concentrations increase to amaximum at about 46 h, and may reach >1500 nmollitre1 depending on the severity of the surgicaltrauma. The cortisol response can be modified byanesthetic intervention


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Usually, a feedback mechanism operates so thatincreased concentrations of circulating cortisol inhibit

further secretion of ACTH.This control mechanism appears to be ineffective aftersurgery so that concentrations of both hormonesremain high.


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Cortisol has complex metabolic effects oncarbohydrate, fat and protein.It promotes protein breakdown and gluconeogenesis

in the liver. Glucose use by cells is inhibited, so thatblood glucose concentrations are increased.Cortisol promotes lipolysis, which increases theproduction of gluconeogenic precursors from thebreakdown of triglyceride into glycerol and fatty acids.


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Cortisol has other glucocorticoid effects, notably thoseassociated with anti-inflammatory activity.Corticosteroids inhibit the accumulation of

macrophages and neutrophils into areas ofinflammation and can interfere with the synthesis ofinflammatory mediators, particularly prostaglandins.


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Growth hormone

Growth hormone is a protein of 191 amino acids

secreted from the anterior pituitary. Its release isstimulated by growth hormone releasing factorfrom the hypothalamus. Growth hormone.Many of its actions are mediated through small

protein hormones called insulin-like growthfactors (IGFs), notably IGF-1, which is produced inliver, muscle and other tissues in response tostimulation by growth hormone.


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In addition to the regulation of growth, growthhormone has many effects on metabolism.

1- It stimulates protein synthesis.2-inhibits protein breakdown.3-promotes lipolysis (the breakdown oftriglycerides into fatty acids and glycerol) .

4-has an anti-insulin effect.This means that growth hormone inhibits glucoseuptake and use by cells, which spares glucose foruse by neurones in situations of glucose decrease.5-Growth hormone may also stimulateglycogenolysis in the liver.


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Growth hormone secretion from the pituitaryincreases in response to surgery and trauma, inrelation to the severity of the injury.


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-Endorphin

-Endorphin is an opioid peptide of 31 amino acidsproduced from the anterior pituitary.

Increased -endorphin concentrations in thecirculation after surgery reflect increased pituitaryhormone secretion. The hormone has no majormetabolic activity.


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Insulin

Insulin is the key anabolic hormone.

Insulin concentrations may decrease after the

induction of anesthesia, and during surgery there is afailure of insulin secretion to match the catabolic,hyperglycaemic response. This may be caused partlyby -adrenergic inhibition of cell secretion.


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In addition, there is a failure of the usual cellularresponse to insulin, the so-called insulin resistance,which occurs in the perioperative period.


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Glucagon Glucagon is produced in the cells of the pancreas.

This hormone promotes hepatic glycogenolysis.It also increases gluconeogenesis from amino acids in

the liver has lipolytic activity.


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Although plasma glucagon concentrations increasetransiently after major surgery, this does not make amajor contribution to the hyperglycaemic response.


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Water and electrolyte metabolism

A number of hormonal changes occur in response tosurgery which influence salt and water metabolism.

These changes support the preservation of adequatebody fluid volumes.


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vasopressin secretionArginine vasopressin, which is released from the

posterior pituitary, promotes water retention and theproduction of concentrated urine by direct action on

the kidney. Increasedvasopressin secretion may continue for 35 days,depending on the severity of the surgical injury andthe development of complications.


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Renin is secreted from the juxtaglomerular cells of thekidney, partly as a result of increased sympatheticefferent activation. Renin stimulates the production of

angiotensin II. This has a number of important effects;in particular, it stimulates the release of aldosteronefrom the adrenal cortex, which in turn leads to Na+and water reabsorption from the distal tubules in thekidney,


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Interaction between the immune system

and the neuro-endocrine system

In patients after surgery, cytokines IL-1and IL-6 mayaugment pituitary ACTH secretion and subsequentlyincrease the release of cortisol. A negative feedback

system exists, so that glucocorticoids inhibit cytokineproduction. The cortisol response tosurgery is sufficient to depress IL-6 concentrations


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Cytokines The cytokines have a major role in the inflammatoryresponse to surgery and trauma.They have local effects of mediating and maintaining

the inflammatoryresponse to tissue injury.Also initiate some of the systemic changes whichoccur. After surgery.


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the main cytokines released are :interleukin-1 (IL-1),tumour necrosis factor- (TNF- )

IL-6. Theinitial reaction is the release of IL-1 and TNF-from activated macrophages and monocytes in thedamaged tissues. This stimulates the production

and release of more cytokines, in particular, IL-6,the main cytokine responsible for inducing thesystemic changes known as the acute phaseresponse


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Interleukin-6

This is a 26 kDa protein. Concentrations ofcirculating cytokines are normally low and may beundetectable. Within 3060 min after the start ofsurgery, IL-6 concentration increases; the changein concentration becomes significant after 24 h.Cytokine production reflects the degree of tissue

trauma, so cytokine release is lowest with the leastinvasive and traumatic procedures,


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The acute phase response A number of changes occur following tissue injury whichare stimulated by cytokines, particularly IL-6. This isknown as the acute phase response;one of its features is the production in the liver of acutephase proteins These proteins act as inflammatorymediators: They include C-reactive protein (CRP),fibrinogen, 2-macroglobulin and other anti-proteinases.The increase in serum concentrations of CRP follows thechanges in IL-6. Production of other proteins in the liver,for example, albumin and transferrin, decreases during the

acute phase response. Concentrations of circulatingcations such as zinc and iron decrease, partly as aconsequence of the changes in the production of thetransport proteins


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Stress reduction protocol Before appointment. During

appointment. After appointment.


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Before appointment - Hypnotic agent to promote sleep on night before

appointment. - Sedative agent toreduce anxiety on morning of surgery.

- Minimize reception room time. - Morningappointment. -Short appointment.


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During appointment - Frequent verbal reassurance. - Distracting

conversation. - No surprise.- Instruments must be out of patients sight.

- Relaxing background music. - Adequateand profound L.A. - Nitrous oxidesedation.


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After appointment - Postoperative instructions. - Inform

patient on expected postoperative sequels.- Further reassurance - Effective

analgesic - Means of contact.


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Methods used for Management of pain &

anxiety in dentistry Local anesthesia.

Sedation with Local anesthesia.

General anesthesia


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Anesthesia in dental practice divided into: I - Anesthesia in the dental chair.

2 - Anesthesia for minor oral surgery:

Day- stay surgery.

inpatient surgery.

3 - Anesthesia for major oral and maxillofacialsurgery:

Elective surgery.

Emergency surgery..


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Analgesia Means a state of painless or insensible to pain

It restricted to loss or reduction of pain sensation withrelative preservation of other modalities of sensation.


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Anesthesia means insensible, or without feeling. It denotes loss of

all modalities of sensation


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General anesthesia It is a reversible state induced by pharmacological

agents that resulted in loss of consciousness ,inhibition of the spinal reflexes and lack of overt

muscular response to surgical stimulation. The processmust be


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Local anesthesia: Elimination of sensation and motor activity in one part

of the body by topical application or regionalinjection.


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Selection of anesthetic agent and technique

based primarily upon

the patient condition.

The requirement of anticipated surgical intervention finally on the patient preference.


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The patient condition American society of Anesthesiology classified patients

according to their physical state as following:


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ASA class 1= No organic, physiologic, biochemical,or psychiatric

disturbance.

ASAclass 2 = Mild to moderate systemicdisturbance that may or may

not related to the reason of surgery.

Examples : Heart disease that only slightly limitsphysical activity , essential , hypertension ,diabetes mellitus , anemia , extremes of ages,morbid obesity, chronic bronchitis.


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ASAclass 3 Severe systemic disturbance that may ormay not related

to the reason of surgery.

Examples: Heart disease that limits activity , poorlycontrolled essential hypertension, D.M with vascularcomplications, chronic pulmonary disease that limitsactivity , angina pectoris, history of prior myocardial

infarction.


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ASA class 4 = Severe systemic disturbance that is life -threatening with or without surgery.

Examples: Congestive heart fafinre , persistent anginapectoris , advanced pulmonary , renal or hepaticdysfunction


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ASA class 5 : Moribund patient who has little chance ofsurvival but is submitted to surgery as a last resort.

Examples : Uncontrolled haemorrhage as fromruptured abdominal aneurysm , cerebral trauma

pulmonary embolus.


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Emergency operation (E): Any patient in whom anemergency operation is required.


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Assessment of the patient History.

Physical examination.

Investigations. Premedication


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Local anesthetic drugs Local anesthetic drugs act mainly by inhibiting sodium

influx through sodium-specific ion channels in the

neuronal cell membrane. When the influx of sodium is

interrupted, an action potential cannot arise and signalconduction is inhibited.


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Local anesthetics reversibly eliminate sensationconducted along peripheral nerves by blocking theentry of sodium (Na+) into the sodium channeland thus preventing these depolarizations, therebypreventing the transmission of pain information.The charged (ionized) form of the local anesthetic

molecule blocks nerve conduction more effectivelythan the uncharged base.


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Respiratory system Cardiovascular systemC.N.S. Renalsystem

Liver


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Respiratory system Inhibition of the respiration.

Central Inhibition of the chemoreceptors.

Inhibition of the ventilation.

Increase the airway resistance and physiological deadspace.


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EffectAnesthesia acts on the cardiac pump function* preload

* contractility

* after load.


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PreloadAnesthesia modifies the preload by increasing thecapacitance of venous system through

direct effect on vascular smooth muscle

and reduction in sympathetic tone.


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ContractilityWith the exception of ketamine , most if not all

anesthetics decrease myocardial contractility.


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Anesthesia modifies sympathetic and vagal

tone. The heart rate and arterial pressure are increased

during cannulation and induction due tosympathetic overactivity. This can be avoided by

premedicant sedation.Also the procedures of laryngoscopy andintubation produce tachycardia, hypertension anddysrhythmias . This ia sympathomimetic response

which can be prevented by provision of an

adequate depth of anesthesia before intubation The process of intubation can stimulate vagal

response leading to bradycardia which isprevented by the use of anticholinergic drugs.


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Renal system * Effect on the systemic circulation * Effect on

the sympathetic nervous system.* Effect on the endocrine function. * Direct

nephrotoxic effect.


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Effect on the liver Inhalational anesthesia Surgical

stimulation-> reduce hepatic blood flow. Associatedwith hepatic dysfunction:

*Increase of body temperature. Increase *Increaseplasma transaminase enz. *Eosinophilia*Jaundice


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Anesthetic & sedative drugs Inhalational anesthesia Injectable

drugs


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Inhalational anesthesia:

By using volatile lipid soluble gas or vapour. Thismethod is used for maintenance of general anesthetic,and under some instances used for induction.


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Inhalational anesthesia Ether Nitrous oxide

Halothane EnfluraneIsoflurane Desflurane

Sevoflurane

ideal inhalational anesthetic agents should


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ideal inhalational anesthetic agents should

have certain properties:

(1) Pleasant odour. (2) Neither flammable nor explosive. (3) Not irritant to the respiratory tract. (4) Low blood/ gas solubility which permit rapid induction

and recovery. (5) Can produce unconsciousness with analgesia, and

preferable some degree of muscle relaxation. (6) Not metabolised in the body. (7) Minimal cardiovascular and respiratory depreshe effects. (8) Allow the use of high inspiratory oxygen concentration

Some Inhalational Anaesthetic Agents:


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Nitrous oxide : It is a colorless, non irritant and non flammable gas, supplied a liquid in blue steel cylinders under pressure. It is weak anesthetic, but

potent analgesic agent so it can not be considered as a sole inhaleddrug for providing adequate anesthesia.

It is relatively insoluble and thus its partial pressure in the blood andtissues rise rapidly providing rapid onset of action. Also it is rapidlyeliminated from the lungs facilitates rapid recovery. But during the

few minutes of this elimination , large volumes pour out of the bloodInto the lungs and displace oxygen causing what is called diffusionhypoxia.


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Halothane The most popular volatile anesthetic in the

practical use. It is clear colourless, non f lammable

volatile liquid . It is potent anesthetic but has aweak analgesic effect. It provides rapid smoothinduction , easy maintenance of proper depth ofanesthesia and comfortable recovery. In highconcentration , it may produce respiratory and

cardiovascular depression. It should not beemployed more then every three months, ashepatotoxicity may occur. Also it sensitize themyocardium to the circulating catecholamines.


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Enflurane:A clear , colorless, stable volatile liquid which is

physically and pharmacologically related to halothane.


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Enflurane

A clear , colourless, stable volatile liquid which isphysically

pharmacologically related to halothane.

It is non irritant to the respiratory system , providesrapid induction and recovery. It has less arrhythmiceffect than halothane,

it is more expensive. It is not suitable for patients withrenal diseases or epilepsy.


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Isoflurane:

It is potent respiratory depressant agent. Unlikeenflurane,

it does not promote convulsive activity.

It sustains the myocardial contractility.


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Sevoflurane:

It has an attractive anesthetic features: It ispleasant and not pungent. Its induction is rapid andsmooth , especially important in pediatric outpatients.

It produces rapid and complete recovery. No organtoxicity , less incidence of nausea and vomiting. It hashaemodynamic stability. and no cardiac sensitizationto catecholamines


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Injectable anesthesia

By using drugs which depress CNS. these includesedatives, tranquillizers and hypnotic drugs.


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The ideal injectable anesthetic drug must

be:

(1) Rapid in onset and recovery. (2) Has an analgesic effect at subanesthetic dose.

(3) Not releasing for histamine. (4) No emetic effect. (5) No excitatory phenomena cough , hiccup , or involuntary

movements on induction. (6) No emergence phenomena e. g. night mares. (7) No venous squeal or pain on injection. (8) Safe if accidentally injected in an artery. (9) Minimal cardiovascular and respiratory effects. (l0)No organ toxicity


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Injectable drugs Thiopentone sodiumMethohexitone KetaminPropofol

Benzodiazepines Opiodis


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Thiopentone sodium:

the most widely used anesthetic agent, supplied invials containing a yellow powder. It produces rapid,pleasant induction.

It must given by slow intravenous injection. It is thedrug of choice in epileptic patient.


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But it has respiratory and cardiovasculardepressive effects.

Extra venous injection causes severe Irritation totissues resulting in

pain, redness and swelling. Necrosis and ulcerationmay occur. If accidentally injected in an artery, it

causes spasm with subsequent thrombosis whichmay lead to gangrene.


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Methohexitone It is a safe reliable drug with good early recovery,

free from nausea and vomiting

It has low incidence of anaphylactic reactions, butit is absolutely contraindicated in epilepticpatients.

Injection pain is a real problem especially whensmall veins on the dorsum of the hand are used.


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Propofol The most recent agent with sedative hypnotic

properties. It is

highly lipophilic, metabolized in the liver andeliminated by the Kidney. It produces hypotension,apnea and pain on injection.


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Indications of G.A. and sedationYoung children.Apprehensive and non cooperative. Mentally handicapped patients.

Surgery in more than one quadrant.Acute infection. Previous radiotherapy to the Jaw.Allergic reactions to local anesthetic agents. Medically compromised patients. Long procedure.


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Contraindications of general anesthesia in


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the dental chair:

* Unprepared patients as history of recent meal.

Patient with sever oral infection.

Unaccompanied patient.

Patient with serious medical disease.


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DENTAL CHAIR AND POSTURE

Semi recumbent position with elevated legs givesan ideal position for respiratory and cardiovascularconditions.

Therefore , it is important to use a dental chairwith an adjustable head-rest allowingmanipulation of the head and neck on the trunk.

The chair must also be capable of being placed inthe horizontal position rapidly for the possibilityof cardiopulmonary resuscitation when needed.


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ANALGESIA AND SEDATION

The American Dental Association council on DentalEducation has proposed specific definitions forsedation and analgesia during local anesthesia:


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Analgesia Diminution or elimination of pain in the consciouspatient.


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Conscious sedation Depressed level of consciousness which allows thepatient the ability to independently and continuouslymaintain an airway and respond appropriately to

physical stimulation and verbal command.


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Deep sedation ( hypnosis) Controlled state of depressed consciousnessaccompanied by partial or complete loss of protectivereflexes, including the ability to independently

maintain an airway and respond purposefully tophysical stimulation or verbal command.

L l f i d ti


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Levels of conscious sedation:

Level 1: A wake and calm ( no evidence of .drowsiness)

Level 2: A wake but sedated ( slurred . . .

speech) Level 3: A sleep but easily aroused ( . . .

verbally)

L l f D d ti


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Levels of Deep sedation

Level 4: A sleep but difficult to arouse(shake or shout)

Level 5: A sleep and unarousable except by surgical

stimuli


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it must be remembered that controlled sedation cannot compensate for inadequate local analgesia. Alsoprolonged preoperative starvation may lead to

hypoglycemia and fainting.


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Criteria of the drugs used in sedation The drug used should produce reliable sedation

without loss of consciousness.

It should have a wide safety margin , with minimal

cardiovascular and respiratory depression.Also it should produce rapid recovery to Street fitness.

methods used to produce


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methods used to produce

sedation Oral sedation:

Intramuscular sedation.

inhalational sedation.

Intravenous sedation.


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The most common types of Sedation

(Sedation Dentistry) used by Generaland Restorative Dentists who utilize

sedation are:

Oral Conscious Sedation

Inhalation Sedation


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Oral Sedation This Oral Medication used for Oral Conscious

Sedation in dentistry are from a group of drugs knownas Benzodiazapines. Not only do these medications

have a sedative effect they also have some degreeof amnesic effect for most people. Patients rememberlittle or nothing about their dental appointment.
http://www.nlm.nih.gov/medlineplus/druginfo/uspdi/202084.htmlhttp://www.nlm.nih.gov/medlineplus/druginfo/uspdi/202084.html


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With Oral (Enteral) Conscious Sedation andInhalation Conscious Sedation, the patient willexperience a state of very deep relaxation. You can still

speak and respond to the requests of others. Since IV Sedation requires specialized training and

certification it is not used in most general practices.

Advantages of Dental Oral


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Advantages of Dental Oral

Sedation: Easy to administer: Swallow a small pill

It is safe and easy to monitor

Works well for most people

Low Cost

Disadvantages of Dental Oral


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Disadvantages of Dental Oral

Sedation: The level of Sedation is not easily changed

Someone must drive patient to and from dentalappointment

There is no analgesic (pain relief effect)

medications are used for Dental


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medications are used for Dental

Oral Sedation The most common medication is triazolam. It

provides a deep levelof relaxation and amnesia effect.

For children the most common medication is Versed

(Medazolam) which is a liquid.


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Inhalation Conscious Sedation Nitrous Oxide and Oxygen ("laughing gas") has been

used as the most frequent and primary means ofSedation used in Dentistry for many years.

The safety features of the machine insure that thepatient receives no less than 30% Oxygen mixed withNitrous Oxide. Usually the patient receives 50 to 70%Oxygen.


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Nitrous oxide is colorless, odorless, non- irritating andrelatively insoluble in the blood as BIG partitioncoefficient 0.47 .The use of nitrous oxide through a

nosepiece in increasing concentrations starting at 10%up to 30% will produce sedation, analgesia andamnesia. A state commonly termed relative analgesia.


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This technique is safe , reliable , and produce rapidrecovery .

Continuous observation of the patient throughout

sedation for signs of light- headedness, tinglingsensation, warmth, f loating, heaviness and smile isindicated.

At the end of the procedure, 100% oxygen must beapplied for 5 minutes with

continuous vital signs monitoring.


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Disadvantages of Dental


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g

Inhalation Sedation: Severe anxiety may require a deeper level of sedation

Not indicated for people who have respiratoryproblems (Asthma and Emphysema)

Claustrophobic patients do not like anything coveringtheir nose

Diffusion hypoxia.


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Deep Conscious Sedation.IV Sedation also known asDeep Conscious

Sedation is usually used by Oral Surgeons anddentists with specialized training and specialcertification.

With this type of sedation, medications areadministered directly into the blood stream.

IV Sedation is not used commonly in most dentaloffices because of the specialized advanced

training required and the requirements forcertification.

The greatest advantage of IV


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g g

Sedation is that if someone is not sedated enough, the doctor

can administer more medication and the effects areinstantaneous.

The drugs used for IV Sedation are more effective thenthe same drugs taken orally. There is a more profoundamnesia associated


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Intravenous sedation It is the preferred route for controlled sedation as it is

possible to titrate the drug precisely against effect.

Jorgensen technique


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g q

It is one of the original and best known methods ofinravenous sedation. Pentobarbitone in 10 mg is

injected every 30 seconds untile the patient isrelaxed , and lightly sedated. The supplemented bya mixture of pethidine 25 mg and hyoscine 0.3 mgdiluted in 5 ml.

This technique although relatively safe , requireslong induction and recovery times , patients haveprolonged hangover effects.

Benzodiazepines


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p

Properties:

* anti-anxiety,

* anti-convulsion,

* sedation,

* muscle relaxation,

* amnesic properties.


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Benzodiazepines dugs

Diazepam : The most popular drug used forcontrolled sedation . It is very effective anxiolytic.

It produces amnesia and mild sedation , but it hasno analgesic effect, injected dose of 2.5-5 mg every30 sec. untile satisfactory sedation is reached ,diagnosed by verrills sign (Dropping of the upper

eyelid). But it is a potent respiratory depressive ,produces transient tachycardia. Slow recovery mayneed at least one hour and recurrence ofdrowsiness is common.


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Midazolam : It is of short half life , highly lipophilicwith anxiolytic sedative and amnesic properties. Withthe introduction of flumazenil , a specific

benzodiazepine antagonist , midazolam is usedextensively in the outpatient dental clinic , it permitrapid return to normal activity than diazepam. Themean dose 0.14 mg/kg.


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It can be administered IV, IM, P0, rectally, or nasally.

The most common route of administration is IV.


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Midazolam is a potent sedative agent that must begiven slowly. Administration over 2 or more minutes isprudent.

Never give as a single large bolus dose. Rapid or excessive IV doses may result in respiratory

depression or arrest. If not recognized and treatedpromptly, death or hypoxic encephalopathy may

result.


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Lorazepam: is another inexpensive compound ofincreased potency.

It may be delivered sublingually as well as P0, IM, and

IV. Intravenously. it has a relative fast onset of action within 5 minutes -

but has a long duration of action - 3 to 4 hours - andeven longer in the elderly.

Narcotics


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Narcotics are naturally occurring or synthetic opioidsthat act to provide:

analgesia,

sedation, elevate the pain threshold.


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Narcotics classificationAccording to their activity at the opioid receptors in to:

agonists,

mixed agonists-antagonists,

partial agonists


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Naloxone: (Narcan) It is a pure narcotic antagonist. It competes for the

receptor sites thereby reversing the effect of thenarcotic.

It is important to note that all opioid effects arereversed in parallel. This means that rapidinjections of naloxone not only reverse sedationand respiratory depression, but analgesia as well.This sudden unmasking of pain may result in

significant sympathetic and cardiovascularstimulation, which in turn can cause hypertension,stroke, tachycardia, arrythmias, pulmonaryedema, congestive heart failure, and cardiac arrest.


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Naloxone can be given in 0.1-0. 2mg dose andrepeated every 2- 3 minutes until the patient isalert with adequate ventilation yet without

significant pain or discomfort. The effects are seen in 1- 2 minutes and last from

1-4 hours. The half-life of Naloxone is 60-90 min.

Because of this short half-life, patients can

become narcotized after the effects of naloxonehave worn off. Patients should be closelymonitored to watch for renarcotization.

Combined use of benzodiazepines andnarcotics:


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narcotics:

The combined use of diazepam and fentanyl producesedation amnesia and analgesia. But they producesevere respiratory depression and delayed recovery.

Also combined use of midazolam and the agonist-antagonist nalbuphine is used with promising results.


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Katamine

It produces profound analgesia and amnesia. But itproduces emergence reactions such as muscle

spasm , unpleasant visual and auditory illusions ,and depression. The combined use ofbenzodiazepins and ketamine can reduce theincidence of these emergence reactions. Sedative

doses of ketamine is 0.2 - 0.8 mg/kg. It is moreaccepted in children than adults.

Propofol


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Subhypnotic dose 25 - 75 mg./kg /min. producessedation and amnesia.

It can be used alone or in combination with narcotics

or benzodiazepines. It is a promising drug in outpatient dental

surgery.


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Neuroleptanalgesia:

It is a state produced by the use of a combination of , a neuroleptic drug( usually droperidol ) and a strong analgesic (e.g. fentanyl).

It provides effective analgesia in a conscious cooperative and tranquilpatient, but it may cause a marked respiratory depression .So careful

and continuous monitoring of respiration is indicated. Also availabilityof oxygen and airway support must be prepared. evaluation of the levelof respiration assessed and vital signs should be taken. It should benoted that watching the chest or reservoir bag move is not adequate toassure an adequate minute volume. Skin color has been relied on in thepast as a way of assuring adequate tissue profusion. However, thearterial oxygen level can be dangerously low before we see the bluetinge of cyanosis. Anyway, cyanosis is no longer considered to be anadequate monitor of arterial oxygen levels. In this case a pulse oximeterand capnograph is invaluable in assessing the adequacy of ventilation.


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deep sedation or Monitored Anesthesia Care (MAC), uses

medication to induce a controlled state ofdepressed consciousness or unconsciousness in

which the patient may experience partial orcomplete loss of protective reflexes including theability to independently and continuouslymaintain a patent airway. The deeply sedatedpatient may not be easily aroused and may notpurposefully respond to verbal commands orphysical stimulation. This deep sedation may beadministered by dentists certified to do this only.


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It should be recognized that various degrees of sedationoccur on a continuum. A patient may progress fromone degree of sedation to another depending on :

their underlying medical status, the medications administered, dosage and route of

administration.


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It is important therefore that the monitoring andstaffing requirements be based on the patients acuityand the potential response of the patient to the

procedure. Progress from one level of sedation toanother requires appropriate changes in monitoringand observation of the patient.

Patient Selection


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Conscious Sedation is not for every patient - there is aevaluation process that must be considered.


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The American Society of Anesthesiologists (ASA)recommends that conscious sedation be used for:

ASA Class I & II patients, as these patients are the lowestrisk.

Patients classified as ASA Class III may requireconsultation and collaboration by the health care team todetermine if they are appropriate candidates for conscioussedation, or if Anesthesia assistance is needed.

ASA Class IV & V patients must have involvement of theDepartment of Anesthesiology. These patients are notcandidates for conscious sedation and must haveMonitored Anesthesia Care.


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Patient Assessment

All patients require:

a documented history: current medications, allergies,pertinent medical & anesthetic history

physical evaluation on the chart prior to receivingconscious sedation.

The assessment should include, baseline vital signs,weight, airway status,, mental status, and lab studies.

Elderly patients, very young patients, those with kidney .orliver metabolism problems, and psychologically immatureor developmentally disabled patients may need alternativemethods of sedation and anesthesia.

Selection of drug used for


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sedation The drug used depend on the type, duration and

intensity of the procedure

Differences in patients health status with variable

ability to metabolize medications should beconsidered when selecting and administering themedications.

Agents Used for Conscious Sedation


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g

Conscious sedation is achieved by administeringpharmacological agents. The most common routeof administration is intravenous (IV), althoughmedications may be given orally (P0), rectally,

intramuscular (IM), subcutaneously (SQ), ornasally.

The most commonly used agents arebenzodiazepines, narcotics, barbiturates, and

certain hypnotics (such-as chloral hydrate).

Equipment and Supplies


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Prior to sedating the patient the health carepractitioner needs to assure that all monitoringequipment required for conscious sedation is present

and functioning.


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Suction: Apparatus capable of producing continuous negative pressure of l50torr.

Oxygen: System capable of delivering 100% at 10 L /min. for at least 30minutes. Airway Management: Face masks (all sizes), Oral and nasal airways,

endotracheal tubes,Laryngoscopes. Monitors: Pulse Oximeter with both visible and audible displays cardiac

monitor, automated Blood Pressure Device. Resuscitative equipment &Medications: Ambu Bag, Defibrillator with ECG

recorder capabilities, Emergency Drugs,


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conscious sedation depresses the level ofconsciousness while allowing the patient to maintaintheir airway independently, the physician s

responsibility must focus on assessing parameters thatmay be impacted by sedating medications.


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Observation of the patient before, during and after theperiod of sedation is crucial. Discrete changes inpatient status are often observed before noticeable

changes in vital signs and other parameters occur.


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Consistent with the ABCs of resuscitation - Airway,Breathing, and Circulation - the ability to positionallymaintain an open airway should be assessed and

documented by determining the level of consciousnessand reusability of the patient. Baseline level ofconsciousness prior to the sedation should also beassessed and documented.


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Breathing should be assessed through the usecontinuous pulse oximetery and observation ofrespiratory rate, depth and effort.


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Circulation should be assured through blood pressure,pulse and cardiac rhythm monitoring. Hypoxemiafrom any cause is often reflected by cardiac

dysrythmias (especially bradycardia), necessitating theneed for continuous heart monitoring throughout theperiod of sedation and recovery.


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Hemodynamic changes reflect physiologicalalterations such as circulating volume changes,vasoconstriction, vasodilatation and other effects of

sedation or the accompanying procedure.


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A patent intravenous sit should be established andmaintained throughout the recovery stage of sedation.

Resuscitation equipment and personnel skilled in

advanced life support including airway managementshould also be available.


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Dyspnea, apnea, or hypoventilation, inability toarouse the patient, the need to maintain the patientsairway mechanically, or other undesired or unexpected

patient responses.


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Patient should be monitored and documented atleast every five minutes.

Once the patient parameters have returned to pre-

sedation levels, or at least 30 minutes has passedsince the last sedating medication, monitoring ofphysiological parameters may be increased toevery 15 minutes until the patient returns to pre-sedation level of consciousness and stability.

Discharge Criteria


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Patients to be discharged should be:

1. Stable out of bed for 30 minutes prior todischarge.

2. Able to void. 3. Able to retain oral f luids.

4. Discharged with a written physicians order andfollow up instructions.

5. Under observation of a responsible person andhave transportation from the hospital.

approved for administration topediatric patients for conscious


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sedation:

Chloral hydrate (P0 or PR),

diazepam (IV),

Midazolam (P0, IM, or TV)

Fentanyl (IV or TM),

morphine (IV or IM).

Dosage is extremely important and is usually

calculated on weight so an accurate weight mustbe obtained prior to medication administration.

Complications of sedation:


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Overdose or adverse drug reactions may cause:

respiratory depression,

hypotension,

impaired cardiac function.

Airway obstruction.


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Emergency interventions include, but are not limited to:

airway management.

reversal of sedating medications.

other measures such basic life and advanced cardiaclife support.

Management of Respiratory Depression


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Respiratory depression should be treated with :

airway management.

Oxygen.

The most effective way to open the airway is the headtilt-jaw lift. Often this maneuver alone is enough toimprove ventilation and 02 saturation.


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Every patient should have oxygen via nasal cannulathroughout the procedure.

If the patient is breathing and the oxygen saturation is low,the flow of the nasal cannula 02 may be increased.

Encourage the patient to take deep breaths. If the patient isbreathing but the oxygen saturation remains low, changethe nasal oxygen to a 100% nonrebreathing facemask.

If efforts remain unsuccessful, bag the patient by

connecting the facemask to an ambu-bag. Continue to bagthe patient until the oxygen saturation improves.

If the condition does not improve, intubate the patient.


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If the patient is breathing and has adequate oxygensaturation but cannot maintain his or her own airway,an artificial airway is indicated.

A nasal or oral airway may be used.

The nasal airway may be more tolerable than an oralairway for a conscious patient.


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The appropriate size nasal airway should be selectedby measuring the distance from the tip of the patientsnose to the earlobe. Apply lubricant and insert into

one nostril. If resistance is encountered, slight rotationof the tube will facilitate insertion.


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The oral airway size is determined by measuring thedistance from the corner of the patients mouth to theearlobe.

C di C li ti


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Cardiac Complications Hypotension.

Cardiac arrythmias.

H t i


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HypotensionIt is easily corrected by placing the patient in

trendelenburg (head-down) position and giving IVfluids.

ANAESTHESIA FOR MINOR

ORAL SURGERY


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This one short operation lasting about 20-40 minuteson average, and rarely exceeding one hour.

The anesthetic managements depend on whether the

surgery is day - stay or in patient surgery.

Criteria used to select patient for day stay


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surgery

1 - The patient must be of ASA class 1 or II categories.

2 - The surgery must be straight forward and notexceeding one hour.

3 - The social condition of the patient must beadequate for postoperative care at home.

pre operati e preparation


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preoperative preparation Patients must fill in an anesthetic questionnaire, complete

physical examinations and investigations as mentionedbefore.

It is best to operate in the early morning, as this allows full

time for recovery and reduces the period of pre-operativestarvation.

premedication is better to be avoided as sedative drugs willdelay recovery.

It is acceptable to allow clear fluids by mouth up to 4 hoursprior to surgery except in very anxious patient.

Induction


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Anesthetic technique is extremely important inday-stay surgery , as it is vital that post-operativemorbidity is reduced to a minimum in ambulantpatients returning borne.

The patient is put in semireclining position. Thisposition allows good visualisation of the larynx. Allthe vital signs insist be checked, then a cannula isinserted, induction is usually with intravenousdrugs except in young children inhalationaltechnique is used


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Most of these patients will require trachealintubations, although few can sometimes bemanaged with nasopharyngeal airways and carefulpacking.

Laryngeal mask used with increasing frequencyfor this type of minor surgery.

Nasal intubations is preferred than oralintubation as it provides free field for the surgeon.

The use of topical vasoconstrictor substance suchas cocaine or phenylephrine will reduce theincidence of epistaxis.


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Suxamethonium is the most popular muscle relaxantused for intubation. However, the frequency ofpostoperative muscle pains in ambulant patients and

the occasional prolonged apnae following this drugmake it a less than ideal agent for day-stay units.


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Prior administration of subparalyzing doses ofnondepolaiuing muscle relaxants can reduce the post-operative muscle pain.

Discharge criteria


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There are three stages of recovery followingambulatory surgery namely; early , intermediate , andlate.

The first and second stages occur in the ambulatorysurgical facilities, whereas late recovery refers to theresumption of normal daily activities and occurs afterdischarge.

Early recovery phase


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Early recovery phase It is the time interval during which patients

emerge from anesthesia , recover their protectivereflexes , and resume motor activity .

During this phase of recovery ,patients are caredfor in a phase I post-anesthesia care unit wheretheir vital signs and oxygen saturation are carefullymonitored .

Oxygen supplementation, analgesics , orantiemetics may be dministered.

Intermediate recovery phase


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Intermediate recovery phase During this phase patients are cared for in a reclining chair

and progressively begin to ambulate, drink fluids , void ,and prepare for discharge.

Most ambulatory surgical facilities have a separate phase II

recovery area for the intermediat recovery of outpatients toa home ready state.

The choice of the anesthetic technique as well as post-operative analgesics and antiemetics drugs have an impacton the duration of the intermediate recovery period.

The late recovery period


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The late recovery period It starts when the patient is discharged home and

continues until full, functional recovery is achievedand the patient is able to return to work.

IN-PATIENT SURGERY


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With improving anesthetic and surgical techniquesoutpatient dental anesthesia continue to grow.

However ,patients with the following conditionsappear to be at increased risk of postoperativecomplications and should be offered the option ofovernight hospitalization.

It i i di t d i th f ll i diti


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It is indicated in the following conditions : 1- Serious potentially life threatening diseases that are not optimally

managed (ASA III &IV) 2- When more extensive surgery is going to be done. 3-Morbid obesity complicated by respiratory complications 4-Lack of responsible adult at home to care for the patient on the night

after surgery. 5-The medical condition of the patient, need the patient to be

hospitalized ,or if the patient under is under drug therapye.g.monoamino oxidase inhibitors ,acute substance abuse. 6-The socialcondition of the patient contraindicates outpatient treatment.

Management of anesthesia is done as in

d t ti th i t


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day-stay surgery exception these points:

* Special investigations and preparationsaccording to the medical state of the patient.

* Free selection of preinedication & sedation ispresent.

* Also the selection of anesthetic technique andpostoperative pain relief drugs as narcotics andanalgesics are dependent on the patients

condition with no need for immediate recoveryand early ambulation.

ANESTHESIA FOR MAJOR ORAL AND

MAXILLOFACIAL SURGERY


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These operations may be

either elective or emergency procedures.

Elective operations are divided into three

main categories:


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Corrective operations of the jaws: Such as fracturemandible and building up procedures, which mayinclude the use of bone grafts.

- Removal of tumors of the mandible and maxilla:which ranging from enucleation of simple cysts to

removal of extensive jaw carcinoma.

- Operations on the tongue and floor of the mouth.

I P ti ti


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I - Pre-operative preparation:

Full preoperative assessment of the patients condition, his medical state and ASA classification must be done. Many patients will have abnormal anatomy and considerable problems

for intubations. Difficult intubations is anticipated in the following

conditions: One: Limited mouth opening. Two: Prominent upper teeth. Three: A high arched palate. Four: A receding mandible. Five: A short immobile neck.


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Also certain tumors especially that of the larynx, donot compromise the airway when the patient is awake,but may cause obstruction when the muscle tone islost under anesthesia.


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Awake intubation with local anesthesia is a safetechnique, and it is the method of choice in seriesairway problems. Premedication consists of anantisialogogue, with anxiolytic drug.

Local anesthetic solution may be applied to

the nose, pharynx, and trachea to enable trachealintubation.

II - Induction


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Facilities for emergency tracheostomy must bepresent.

Management of airway intubation through:

I -Aawake intubation 2-nasal intubation using fiberoptic laryngoscopy

3-Cricothyroidotomy

4-Tracheostoy

III- Maintenance:


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Anesthesia is maintained by volatile agents orintravenous drugs using either controlled orspontaneous ventilation.

Neuroleptanesthesia using combination of strong

analgesics such as fentanyls with sedatives of thebutyrophenone type such as droperidol is oftenfollowed by a period of postoperative analgesia andsedation.

Blood loss may be heavy. So the use of inducedhypotension is excellent choice in theseoperations.

IV- Recovery:


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IV Recovery:

Extubation, especially if airway problems areanticipated, is best performed with the patient

awake in the lateral position.A nasopharyngeal airway may be left in place for

easy suction of the pharynx.

Patients are best nursed in an intensive care unit

for the first 24 to 48 hours, especially if the jawsare wired together, and wire cutters should be

immediately available.

Emergency surgery


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It vary from simple fracture to complicated bonyinjuries with associated soft tissue damage.

I - preoperative preparation:


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I preoperative preparation:

First priority must be given to the establishment of a clearairway and restoration of an adequate circulation.

Associated injuries to the head, chest or abdomen mayrequire treatment before correction of maxillofacialdamage

Obstructed airway is frequently present due to blood, teethand bone fragments lying is the pharynx. There may beactive bleeding in the pharynx, and the stomach willcontain blood and food.

The pharynx must be cleaned and suctioned. Thepossibility of concurrent basal skull fracture and thepresence of immobile jaw must be considered .

Patient may be unable to open his mouth

due to the presence of:


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due to the presence of:

Truisms: Spasm of the masseter muscle is acommon cause of immobility .It responds toadministration of anesthetic and muscle relaxant.

If trismus lasted two weeks or more, fibrosis willinvolve the muscle and the truisms will notrespond to anesthetic or relaxant.

Edema: It may limited the mobility, and cause

great problem during intubation.


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Pain: It is the most common cause of immobility andalso respond to anesthetics and relaxants.

Mechanical dysfunction oftempromandibular joint:

where the jaws are locked together.

II - Induction:


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Using pre-oxygenation, followed by an intravenousagent. and suxamethonium. Then a cuffedendotracheal tube is inserted.

When a cerebrospinal fluid leak is present , or there is

a fracture at the base of the skull , it is better to avoidnasal tubes as they may cause meningitis .

III - Maintenance:


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Anesthesia is maintained as in elective operations withthe exception of that in hypovolemic patients it isbetter to use ketamine.

IV - Recovery


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IV Recovery

Patients with immobilized jaws will need special attentionand best nursed in the ICU.

sedation must be kept to a minimum with careful

monitoring of the respiratory system. If tracheal extubation of a patient with a known difficult

airway is followed by respiratory distress , thenreintubation may be difficult or impossible . Thus the idealmethod of extubation is one that permits a withdrawalfrom the airway that is controlled, gradual , step - by - step ,and reversible at any time .

COMPLICATIONS OF DENTALANESTHESIA


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These complications are subdivided into: Respiratory

cardio-vascular,

nausea& vomiting.

I - Respiratory complications:


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I - Airway obstruction: May be caused by the tongue or incorrect positioning

of the mouth prop or pack.


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2 - Mouth breathing:

Is another common problem produced by incorrectpositioning of the mouth prop and pack. Nasopharyngealairway should be inserted.

3 - Apnoea:Either due to breath - holding when anesthesia is too lightor true respiratory depression when anesthesia is too deep.

Apnoea due to excessive anesthesia is a seriouscomplication and the patient must be ventilated with 100%oxygen using a full face mask


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4 - Laryngospasm:It is a serious complication, due to either surgical stimulation underlight anesthesia , or due to the presence of secretion or foreign matterin the larynx

It is important to increase the inspired oxygen concentnration ashypoxia will increase the degree of the spasm.

in severe laryngospasm , it may be necessary to administer oxygen under positive pressure using the mask or intubated

the larynx.5 - Bronchospasm: Less common complication, but may be seen in asthmatic patient

Pulmonry aspiration:


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May be caused by vomiting or regurgitation of thestomach contents, or blood and tooth debris. Correctpacking should be present for absolute safety , trachealintubation is necessary to protect the lungs and ensure

perfect airway during dental anesthesia.

II - Cardiovascular complications


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II Cardiovascular complicationsAlthough respiratory problems are more common,

cardiovascular complications are more serious andmay be lethal, it explains the suddei. death occur inthe dental chair

Cardiac dysrrhythmia


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Cardiac dysrrhythmia There is high incidence of cardiac dysrrhythmias

during general anesthesi for dental surgery.

Hypotension


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Hypotension Venous return decreases and cardiac output

depressed , causing a significant drop in bloodpressure.

Other causes of hypotension at the end of surgery

include inadequate replacement of fluid deficits ,severe pain and gastric dilatation from gases oroxygen.

In the recovering patient who complain of chest

pain and persistent hypotension , myocardialinfarction must be anticipated untill ECG isobtained.

Cardiac arrest:


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Definition:

It is central circulatory and respiratory failure withinability of the heart to maintain adequate cerebral

circulation . The brain is more sensitive to hypoxiathan any other vital organ including the heat. It has alimited facility for anaerobic metabolism and can notstore oxygen.

.Etiology:


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The most common causes of cardiac arrest in the dentalpatients are:

hypoxia resulted from airway obstruction.

vagal reflexes.

Effect of anesthetic agents : either overdose or badtechniques.

Increase the circulatory catecholamines, especially ifthe patients is under halothane anesthesia.

Diagnosis


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Absence of pulse in bigartery.

Cessation ofrespiration.

Pupils : dilated and inreactive to light.
http://en.wikipedia.org/wiki/Image:Carotidian_pulse.png


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In cardiac arrest , the heart may be in one of two forms :Asystole or ventricular fibrillation

Management:


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g

Cardiopulamonary ressuscitation must be done as rapidas possible , in the following steps : A. Airway establishment: The patient rapidly be flat lying on his back. The operator places one

hand under the patients neck and the other hand on the forehead.Then the neck is raised and the head is tilted backwards. This will flexthe neck, extend the head and raise the tongue away from the back ofthe throat, leading to relieve of any anatomical obstruction of theairway.

If there is any suspect of foreign matter in the mouth or throat,clearance by using suction device.

B: Breathing support:


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g pp


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C: Circulatory support

D: Drugs and fluids:


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Oxygen 100% for the treatment of arterial hypoxemia. Adrenalin : either 1: 1000 (1 mglml) or 1: 10000 (1 mg / 10

ml). The dose is 100 ug to 1 mg intravenous or intracardiac.It is & and B. receptor stimulator. Ventriculer tachycardia orfibrillation may be developed.

Atropine : (0.6 to 1.8 mg) Its action mainly trough vogalnucleus. It decrenses vogal tone and increoses heart rateespecially wher due to sinus brodycardia. It is indicated ii.braclycandia and cardiac asystole.

Isoproterenol 2 ug. mm1 to 20 ug. min1 used wher atropme

not effective.


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Lidocaine (2%): 100 mg is indicated in recurrent orrefractory vintricular fibrillation and ventriculartachycardia.

procainamide : 0.75 mg. Kg1 over 5 minutes. Used

when Lidocaine not effective. Bretylium : 5 - 10 mg. kg It is a phormacological

defibrillator used when Lidocaine or procainamideare not effective.

Sodium bicarbonate: 1 m Eq/kg. Slowlyintravenous, if arrest over 5 minutes. Then titrateaccording to the base deficit and pH.


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Verapamil : used in paroxysmal supraventr tachy

cardia 70 ug. Kg1 I. V. initially followed in 15 to 30minutes by 140ug . Kg in persist cardiac dysrhythmias.

Calcium chloride: 10 ml used in selected patientsof hypocalcemia it is

inotropic , but may cause ventricutar asystole intonic contraction.


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E: Electrocardiograph:

Through ECG monitoring.

F: Fibrillation treatment:

Give three initial countershocks by using thedefibrillator to restore the spontaneous pulse lt can berepeated every 1-2 minutes.


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Nausea & vomiting:


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Common problems after general anesthesia. They aredisturbing in outpatients, because they delaydischarge of the patients and may result in unplannedovernight hospital admissions.

The incidence of emesis is very low in infants andgradually increases with towards adulthood.

Risk factors that influence the incidence ofPONY.:


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Medical condition of the patient. Type of surgery. Anesthetics and analgesic medications. patients body habits. pregnancy, usually at the first trimester.

phase of menstrual cycle, most properly during the ovulatory and luteal phase of the cycle. Preoperative stress and anxiety. history of motion sickness. Obesity

Rotine use of prophylactic antiemetic medications is recommended insusceptible patients who have previous history of postoperativeVOmitiflg and in patients with any significant risk factors.

EMERGENCIES IN THE DENTALPRACTICE


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The most important factor in the successfultreatment of medical emergencies is to beprepared for them.

Correct management of the emergency situation

can only follow a correct diagnosis.Very often no drugs are needed but in some

situations drug administration can be a lifesavingprocedure.

Better to give no drug than the wrong one.


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Medical history should be taken prior tocommencing treatment.

Where there is any doubt regarding the patientsstatus, the dentist should consult with the

patients medical practitioner. In cases where the medical condition may be

affected by the dental treatment or which mayaffect dental treatment, it may be necessary, inconjunction with the medical practitioner, toprovide instructions for the patient during theperiod of dental treatment.

Be alert for emergencies.


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Observe the patients reactions during treatment,particularly when drugs are administered.

Be familiar with signs and symptoms of variousemergencies which may occur.

Check emergency equipment and suppliesregularly to ensure that they are not out of dateand that all equipment is working properly.

Following an emergency, patients must not be

allowed to leave unaccompanied.

Epileptic Seizures


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Epilepsy is a condition in which convulsive seizuresare recurrent, although not all recurrent convulsionsare due to epilepsy.

Symptoms can vary from almost imperceptible to the

dramatic loss of consciousness followed by paroxysmsof

tonic clonic seizures.


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Sometimes before a seizure , the person experiences anaura, which can be an unusual sensation, feeling,sound, smell, or urgent need for safety.

In Epilepsy, the aura can serve as a warning ofimpending attack and may give patient time to liedown.


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Stander seizures may seem to last a long time, mostactually only last from about one to three minutes. Thebody may become perfectly rigid

Breathing may become irregular or even temporarily stop.

The eyes may roll back until only the whites show. Fecal and urinary incontinence may occur.

More severe seizures may cause the victim to experiencesudden and uncontrollable tonic- clonic muscularcontractions that last several minutes.

Seizures are classified in to:


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Generalized: arising from deep midline structures inthe brain stem or thalamus ,usually without aura orfocal features during the seizures.

Partial Focal : The initial discharge comes from a focalunilateral area of the brain and usually preceded byaura.

Epileptic seizures can arise from


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discontinuation of sedative hypnotic drugs or alcohol. use of narcotics.

Uremia.

Traumatic injury.

Neoplasms. Infection.

Congenital malformation.

Birth injury.

Hypercalcemia, hypocalcemia. Vascular diseases.


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Status epilepticus is defined as continuous motorseizure activity for more than 20 minutes or asrepeated episodes without undercurrent awakening.

Emergency care of the person experiencing

a seizureTreatment begins with Protect the victim from harm


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g

and maintain the airway: reestablishing an air way ,

administrating oxygen,

ensuring adequate ventilation. Specific treatment is aimed at stopping the seizure

activity by the administration of anticonvulsantdrugs. Commonly employed anticonvulsants include

benzodiazepines and thiopenton sodium.


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After the seizure is over, the victim should be positioned onthe side to help blood and other fluids drain.

The individual may be drowsy and disoriented when theseizure is over and needs to rest.

Abnormal breathing sometimes experienced during theseizure will return to normal.

The victim should be examined and treated for non-life-threatening injuries incurred during the seizure.

Privacy and reassurance should be given.

Diabetic emergencies


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The emergency conditions associated with diabetesinclude :

hypoglycemia, the most acutely life- threatening,

hyperglycemia.,

Management of hyperglycemic

patient


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No dental therapy should be performed whilediabetic hypergiycemia is suspected.

recognizing the condition and referring the patient

to a physician for evaluation and treatment. EMS should be called immediately for the

unconscious patient.

The patient should be placed in the supineposition and basic life support begun.

Hypoglycemia,


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It is acute life-threatening condition. It can result from an insulin over dosage or failure

to maintain normal food intake, usually bydelaying or omitting meals.

It is generally manifested in patients receivinginsulin therapy, but has also been seen in patientstreated with oral hypoglycemic agents, althoughthe condition is less acute in such cases. Althoughsomewhat rare, it is also possible in a person whodoes not have diabetes.


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Hypoglycemia is a true immediate life-threateningcondition with acute onset and may rapidly progress toloss of consciousness. The first manifestations ofhypoglycemia are the result of diminished cerebral

function resulting from a lack of nutrition to braincells.


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Symptoms include decreased spontaneity ofconversation, inability to perform simplecalculations, lethargy, incoherence,

uncooperativeness, and mood changes.

A person experiencing diabetic hypoglycemia issometimes mistaken as being drunk or on drugs.Other symptoms may include hunger, nausea,increased gastric motility (growling stomach),sweating, tachycardia, piloerection (hair feels as ifit is standing on end) and cold and wet skin.


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Any diabetic patient who behaves in a bizarre manneror who loses consciousness should be managed as if hewere hypoglycemic. until proved otherwise since thiscondition is an immediate threat to life.


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A cooperative patient with signs and symptoms ofhypoglycemia should be given oral carbohydrates, such assugar or sugared drink. Recovery is usually rapid anddramatic.

When a person does not respond tocarbohydrates or willnot cooperate, a parenteral carbohydrate, such as glucagonor IV dextrose solution should be given. For unconsciouspatients immediately. Definitive management includesadministration of CHO by IV the most effective method.

Ischemic heart attack emergencies


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When there is deficient arterial blood supply to aportion of the myocardium resulting indeprivation of oxygen and nutrition to the cells ofthe heart muscle. The lack of oxygen and nutrition

for a long enough period of time can cause cellularnecrosis resulted in Myocardial infarction (MI) orheart attack occurs

Angina pectoris occurs when there is a temporary

insufficient supply of oxygen to the heart muscle.


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The victim may describe the pain as a squeezing,heaviness, or a dull ache that lasts only from one to10 minutes.

A person with angina pain generally has had aprevious diagnosis of angina pectoris. Theseindividuals usually carry nitroglycerin to relievethe symptoms.

Vital signs are generally normal during an angina!episode.

Management of Angina


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place the patient in a comfortable position and give his vasodilator, eithernitroglycerin tablet under the tongue, or nitrolingual spray.

Oxygen also may be administered. The symptoms should be relieved within two to three minutes. After the

episode passes, it is best to let the patient rest before continuing dental treatment or

reschedule for another day to continue. If the pain is not relieved, oxygen should be provided and the person assistedin taking a second dose of nitroglycerin. After waiting another two to threeminutes, a third dose may be administered if necessary.

No more than three sprays or three tablets should be administered within a 15-minute period.

three tablets should be administered within a 15-minute period. If pain is not

relieved in the known angina pectoris patient within 10 minutes, the AmericanHeart Association recommends that emergency care must be soughtimmediately

Myocardial Infarction


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MI is of longer duration than angina and is characterizedby more intense pain.

The pain has been described as ranging from discomfort toa crushing substernal pain that can radiate to the shoulder,

arm, neck, or Jaw. Resting, changing position, or taking nitroglycerin does

not relieve the pain.

Often the victim has dyspnea, is short of breath, orbreathes noisily and faster than normal. The skin may be

pale, or cyanotic, and there may be sweating. Some victimsmay be nauseated and may vomit.


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Since MI can lead to cardiac arrest, immediate recognitionand action are critical.

Once a heart attack victim goes into cardiac arrest, thechances of survival decrease.

Most deaths from Ml occur within the first two hours afterthe signs and symptoms occur.

The person should be assisted to rest as comfortably aspossible.

Vital signs should be monitored and preparation to giveCPR begun

Shock


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Cause: Condition where not enough oxygen is reaching the cells

Manifestation (for all forms of shock): Skin is pale, cool, moist

Tachycardia Weak pulse, hypotension Rapid/shallow/gasping respiration Dilated pupils Complains of ringing in the ears / spots in front of eyes Nausea & vomiting Progression from restlessness to apprehension to disorientation to Unconsciousness

General Treatment


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Position with both feet slightly elevated

Ensure adequate airway,

loosen tight clothing Give oxygen if available

Call ambulance

Types of Shock


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*Hemorrhagic Shock

*Cardiogenic shock

*Anaphylactic shock

* Neurogenic shock (Svncope)

Hemorrhagic Shock


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Cause: Decreased blood volume due to: Hemorrhage from 2 sources: External: E.g.: tooth extraction, Internal: E.g.: ulcer, Severe loss of body fluids E.g.: vomiting, diarrhea, burns,

dehydration. Anticoagulant therapy. Manifestation: . obvious bleeding same as for general shock Treatment: Try to control bleeding. Direct pressure

Apply cold. Elevate the area of the body. Dentist can apply a hemostatic agent

Cardiogenic shock


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Cause: Myocardial infarction (heart attack) Heart failure Respiratory arrest/airway obstruction Manifestation:

General shock symptoms. Depends on specific cause: o Myocardial Infarction: persistent chest pain o Heart failure: Severe dyspnea (difficulty breathing) o Airway obstruction: Apnea (breathing stops and starts) Treatment: General shock treatment. Administer CPR. Call ambulance.

Adrenal complications


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I Glucocoticoid Exces

Date post:	14-Apr-2018
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Anesthesia & Sedation in Dentistry

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