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Kyle J. Kramer, DDS, MS
2/24/11
Sedation Protocols
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Goals
! Rational for selecting sedation techniques! Enteral (oral)
!
Parenteral (IV)
! Dental procedures possible while utilizing sedation! Common concerns
!
Common sedation protocols! Enteral (oral)
! Parenteral (IV)
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Goals
! Preoperative instructions for sedation patients
! NPO Guidelines
! Post-sedation protocol
! Discharge criteria
! Common postoperative instructions
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Indications for Sedation
! Comfort and care
! Profound relaxation
!
Long procedures! Invasive procedures
! Behavioral Modification
!
Gagging! Uncooperative nature
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Indications for Sedation
! Anxiety! Situational anxiety
!
Dental phobia
! Medically Compromised Patients! Cardiovascular disease
! Pulmonary disease
!
Cerebrovascular disease! Seizure disorders
! Etc
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Indications for Sedation
! Goal: Adapt YOUR techniques to the patient
! Mix and match!
Extraction = IV sedation!
Implant = Oral + nitrous oxide
! Uncovery = Nitrous only
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Selection Rationale
! Provider preference
! Comfort and familiarity
!
Appropriate licensure!
Adequate training
! Appropriate resources
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Selection Rationale
! Patient selection
! ASA Classification!
How healthy is my patient?! Anticipated problems
! What are they and are you capable of managing the problems?
! Will they tolerate the sedation protocol I have selected?! Example: Conscious sedation on pediatric patients
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Selection Rationale
! Surgical Plan
! How long is the procedure going to be?!
BE REALISTIC!! Does your surgical plan compromise your sedation plan?
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Selection Rationale
! IDEAL: Ability to titrate sedation! Depth of stimulation
! Duration of surgery
! What is expected amount of postoperative pain! Immediate postop
! Usually easily controlled with LA in dentistry
!
Once back home! OTCs
! Rx
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Dental Procedures
! Almost all dental procedures are safe to performconcurrently with minimal or moderate sedation
!
Minor modifications may be needed!
Rubber dam
! Isolite
! C-sponges
! Throat pack
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Dental Procedures: General DentistryProcedures Concerns
! Evaluations
!
Radiographs! Routine treatment
! Drill & fill
! Crown & bridge
!
Implants! Extractions
! Placement
! Uncovering
! Irrigation
!
Loose restorative materials! Alloy
! Implant components
! Obstruction of airway
!
Radiograph holders! Impression trays
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Dental Procedures:
Periodontal TherapyProcedures Concerns
! Nonsurgical
!
Prophy! DSRP
! Surgical procedures
! Open flap debridement
! Soft tissue grafts
! Irrigation
!
Intraoperative bleeding
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Dental Procedures:
Endodontic TherapyProcedures Concerns
! RCT
!
Surgical/invasive therapy! Apicoectomy
! Irrigation
!
Intraoperative bleeding! Obstruction of airway
! Radiograph holders
! Microscope?
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Dental Procedures:
Oral SurgeryProcedures Concerns
! Extractions
!
Invasive procedures! Biopsies
! Tissue grafts
! Incision & drainage
! Irrigation
!
Intraoperative bleeding! Obstruction of airway
! Loose teeth
! Radiograph holders
!
Microscope?
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Key to Success!
! Think through the surgical plan ahead of time and takenecessary precautions
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Oral Sedation Rationale:
Benzodiazepine
! Diazepam, Midazolam or Triazolam??
! Ideal for:
!
Anxious patients! Rest the night before the appointment
! Procedural sedation
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Oral Sedation Rationale:
Diazepam, Midazolam or Triazolam??
! All provide relatively similar levels of sedation at equipotentdoses
!
Anxiolysis! Amnesia possible
! Relatively safe
! Minimal cardiovascular or respiratory depression when usedalone
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Oral Sedation Rationale:
Diazepam, Midazolam or Triazolam??
! Worried about active metabolites (think renal dysfunction!)! Diazepam?
! Maybe not
!
Worried about prolonged recovery/resedation?! Diazepam?
! Maybe not
! Duration of surgical procedure! Diazepam > midazolam = triazolam
!
Diazepam produces slightly different type of sedation
! Patient age! Preoperative midazolam for children
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Oral Sedation Rationale
Diazepam, Midazolam or Triazolam??
! Can combine with nitrous oxide to achieve moderatesedation
!
Requires more monitoring/vigilance!
Monitor for oversedation/hypopnea
! Recommend pulse oximeter
! Obtain baseline, then titrate in N2O!
Able to titrate to level of stimulation
!
Rapid recovery?
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Oral Sedation Rationale
Diazepam, Midazolam or Triazolam??
! Medically compromised patients
! Contraindication?!
Maybe, maybe not! Stress reduction protocol
! Remember: The wholetreatment plan doesnt need to be done at onceespeciallyif the patient isnt doing well
! Use with care!
Go low and go slow
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IV Sedation Rationale
! Benzodiazepine (Solo Agent)
! Diazepam
!
Midazolam
! May be sufficient for some patients depending on theprocedure/situation
!
Anxiety! Minor procedures
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IV Sedation Rationale
! Match the plan to the procedure
! Shorter procedures = midazolam
!
Longer procedures = diazepam (+ midazolam)
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IV Sedation Rationale:
Diazepam verses Midazolam
Diazepam Midazolam
! Dosing:
!
Initial 2.5 mg bolus! Typical dose: 5-15 mgs
! Max: 30 mgs
! Onset: ~1-2 minutes
!
Peak effect: 3-5 minutes
! Dosing:
!
Initial 1 mg bolus! 0.3 mg/kg
! Typical dose: 2-10 mgs
! Max: 20 mg
! Onset: ~1-2 minutes
!
Peak effect: 3-5 minutes
Titrate to desired level of sedation. Give AMPLE time BEFORE redosing
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IV Sedation Rationale:
Combinations
enzodiazepine Narcotic
! Diazepam
!
Midazolam
! Fentanyl
!
Meperidine! Hydromorphone
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IV Sedation Rationale:
Diazepam + Fentanyl
! Duration: Moderate procedures
! Quadrant dentistry
!
~45 minutes
! Ideal for procedures with initial period of stimulationfollowed by mild/minimal stimulation
!
Periodontal surgery! Invasive oral surgery
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IV Sedation Rationale:
Diazepam + Fentanyl
! Intraoperative considerations
! Patients will begin wake up around 30-45 minutes!
Possibly avoid redosing if patient is still comfortable
! Postoperative considerations
! Diazepam active metabolites! Hangover possible
! Resedation is possible as well
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IV Sedation Rationale:
Diazepam + Fentanyl
Diazepam Fentanyl
! Dosing:
!
2-10 mgs! Max: 30 mgs
! Onset: 3-5 minutes
!
Titrate to desired level ofsedation. Give AMPLE
time BEFORE redosing
! Dosing:
!
1-2 mcg/kg! Onset: ~60 seconds
! Start with 1 mcg/kg, add
remaining dose if needed! Helps reduce risk of apnea,
chest wall rigidity
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IV Sedation Rationale:
Diazepam + Hydromorphone (Dilaudid)
! Duration: Moderate-long procedures
!
Prolonged action of hydromorphone! Extended analgesic coverage
! Ideal for procedures where postoperative pain is likely
!
Invasive oral surgery! Periodontal surgery
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IV Sedation Rationale:
Diazepam + Hydromorphone (Dilaudid)
! Dosing:
! Diazepam!
Start 2.5 mg, wait 3-5 minutes before redosing! Hydromorphone
! Start with 0.1-0.2 mg
! Wait ~5 minutes before redosing
!
Titrate to required level of sedation! Anxiolysis
! Analgesia
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IV Sedation Rationale:
Diazepam + Meperidine
! Historically used combination
! Not commonly used anymore
! Meperidine
! Unwanted side effects! Tachycardia
! Risk of serotonin toxicity
!
Risk of seizures (proconvulsant)
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IV Sedation Rationale:
Diazepam + Meperidine
! Phased out of most hospitals
! Still available at Wishard
!
Not available at Clarian/IU Health
! Replaced by cleaner alternatives
! Fentanyl
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IV Sedation Rationale:
Midazolam + Fentanyl
! Extremely common combination
!
Moderate duration! Matches well with typical dental procedures
! Initial dose: ~30-45 minutes of sedation
!
Rapid onset & peak effect! Titration is easily accomplished
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IV Sedation Rationale:
Midazolam + Fentanyl
Midazolam Fentanyl
! Dosing:! Initial 1 mg bolus
!
0.3 mg/kg
! Onset: ~1-2 minutes
! Peak effect: 3-5 minutes
!
Titrate to desired level ofsedation. Give AMPLEtime BEFORE redosing
! Dosing:
! 1-2 mcg/kg
! Onset: ~60 seconds
! Start with 1 mcg/kg, add
remaining dose if needed! Helps reduce risk of apnea,
chest wall rigidity
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IV Sedation Rationale:
Midazolam + Fentanyl
! Minimal postoperative concerns
! No clinically significant active metabolites
! Minimal concerns of resedation
!
Minimal hangover
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IV Sedation Rationale:
Guidelines
!
Rule #1: Go low!!Rule #2: Go slow!
! You can ALWAYS give more
!
But you CANT take it away onceyouve given it..
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Preoperative Instructions
! Review with patients during consult
!
Give patients a hard copy! Include any special instructions
! Hold your multivitamin that morning,
! Take half of your regular insulin
! Be sure to bring your inhaler
!
Bring your CPAP machine
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NPO Guidelines and Oral Medications
! Is it a NPO violation if patients take their regular oralmedication?
! No, as long as.
! 30-60 minutes prior to the appointment
! Taken with a clear fluid
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NPO Guidelines and Oral Medications
! What about patients require taking meds with applesauce?
! Common with mentally disabled patients
! Technically a violation, but we accept the risk
! Minimize risk
! Have patients take meds early as possible! 2-4 hours prior to appointment?
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NPO Guidelines and Oral Medications
! What about oral premedications?
! Antibiotic premeds
!
Oral sedatives
! Not a violation
! Part of the anesthetic/surgical plan
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Preoperative Instructions
! Review NPO guidelines verbally and in writing
! It really does mean NOTHING by mouth
!
Concept:! Reduction in stomach contents
! Volume
! Acidity
! Decreased risk of pulmonary complications if aspirated
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Current NPO Guidelines
! 2 hours
! Clear liquids
! Examples
! Water
! Fruit juices WITHOUT pulp
!
Black coffee! Clear tea
! Carbonated beverages
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Current NPO Guidelines
! 4 hours
! Breast milk ONLY
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Current NPO Guidelines
! 6 hours
! Infant formula
!
Non-human milk! Light meal
! Dry toast and clear liquids
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Current NPO Guidelines
! Meals that include fatty or fried foods or meat may prolonggastric emptying time
!
8+ hours?!
Increased aspiration risk
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Current NPO Guidelines:
Delayed Gastric Emptying
! Concern with certain medical conditions
! Obesity
!
Diabetes mellitus
! Prolong NPO time
! Reduce aspiration risk
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Preoperative Instructions:
Patient Escort
! Escort is responsible for:
! Getting patient home safely
!
Ensuring the patient DOES NOT drive
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Preoperative Instructions:
Patient Escort
! Ideally:
! Arrives with the patient
!
Stays in the office! Is capable of caring for the patient once home
! Postop instructions
! Postop pain meds?
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Preoperative Instructions
! Wear loose fitting clothes
!
No:! Makeup
! Mascara
! Contact lenses
!Jewelry
! Perfume
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Postoperative Instructions:
Discharge Criteria
! Awake, responsive and oriented
! Adequately returned to baseline
!
Peak effect of sedatives
! Minimal/no PONV
! Controlled
! Postoperative pain under control
! Local anesthesia
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Postoperative Instructions:
Discharge Criteria
! Vital signs stable
! 20% of baseline! Blood pressure
! Pulse
! Adequate ventilation and oxygenation
! SpO2 > 90%
!
Should be back to baseline!
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Postoperative Instructions:
Discharge Criteria
! Written postoperative instructions given to patient/escort
!
Discuss any concerns/answer all questions
! Document who patient left the office in care of
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Postoperative Instructions:
Discharge Criteria
! Escort patients directly to their car, rather than dischargethem directly from the chair.
!
Helps prevent any falls, injuries
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Postoperative Instructions
! http://www.youtube.com/watch?v=txqiwrbYGrs&feature=related
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Postoperative Instructions:
Common Directions
! Clear liquids, advance slowly as tolerated
! Avoid fatty or greasy meals
! Stay well hydrated and resume regular meds
! Go home and rest
!
Do NOT drive! Do NOT make any big decisions
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Postoperative Instructions:
Common Directions
! Contact the office if:! Irretractable PONV
! Oral ondansetron
!
Rectal promethazine! Any other concerns or questions
! Patients need to have a method to contact you after asedation/surgery with complications! It is NOT acceptable to tell patients to just go to the hospital
! 911 is ok if life threatening
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Questions???
! Thanks!!