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BDS4 sedation symposium > Inhalation Sedation > Flashcards

Inhalation Sedation Flashcards

1
Q

what are the indications for IS

A
  • Anxiety
    ○ Mild to moderate
    ○ Doesn’t really work for severe
  • Needle phobia
    ○ Carry out needle desensitisation alongside IS
  • Gagging
    ○ Patients with an uncontrollable gag reflex
  • Traumatic procedures
  • Medical conditions aggravated by stress
    ○ Eg asthma
  • Unaccompanied adults requiring sedation
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2
Q

what are contraindications for IS

A
  • Common cold
    ○ Cannot breathe through nose properly and IS relies on being to breathe properly in and out through the nose
  • Tonsillar / adenoidal enlargement
    ○ These patients might be natural mouth breathers and never breathe through their nose so IS is not going to work very well for them
  • Severe COPD
    ○ Because they are not getting enough air in
  • First trimester of pregnancy
    ○ No good evidence that nitrous oxide is toxic in anyway but we just try and avoid it
  • Fear of “mask” / claustrophobia
  • Patients with limited ability to understand
    ○ Cannot do IS on small children - Need to assess children individually on their own merits on whether they have capacity to understand the treatment
    [Some practises have a blanket rule that children must be 7 years and older to go on IS list]
    In terms of adults with special needs they might not understand that you have to breathe through their nose all the time
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3
Q

is IS widely used in GDP

A

IS is not widely used in GDP
It is widely used in community / public dental services and in hospital dental settings
In hospitals they are probably using piped gases rather than the IS machine with the tanks

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4
Q

What is included within IS equipment

A
  • Gas cylinders
    ○ Blue = nitrous oxide
    ○ Black with white top = oxygen
    • Pressure reducing valves
    • Flow control meter
    • Reservoir bag
    • Gas deliver hoses
    • Nasal hood
    • Waste gas scavenging system

= Quantiflex machine

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5
Q

what is the oxygen flow meter

A

○ Measures flow rates of up to 10 L / min○ The reading is taken from equator of ball - Reading is taken from the middle of the indicator ball (silver balls within meters)
○ Accuracy +/- 5%
○ Tells you how much oxygen in L per min that you are providing to the patient - Ie rate of delivery
○ Vertical bar on RHS

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6
Q

what is the mixture control dial

A

○ Shows how much oxygen you are getting compared to nitrous oxide
○ When you move the dial to give them less oxygen then you are giving the patient more nitrous oxide
○ Dial always tells you the percentage of oxygen that you are giving the patient
○ Cannot turn the dial below 30% - it is impossible to deliver any less than 30% oxygen [Very important safety feature]

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7
Q

what is the flow control knob

A

○ This is to do with how many litres per minute the patient is actually getting
§ This is dependent on the patient and on what they need
Black and white bottom part

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8
Q

what is the nitrous oxide flow meter

A

○ Blue
○ Measure flow rates of up to 10 L / min
§ Gauge from the middle of the silver ball
○ Accuracy +/- 5%
§ Ie the patient may actually be having more or less than you think they have
Vertical bar on LHS

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9
Q

what is the air entrainment valve

A

○ If gases fail opens allows room air into circuit
○ If the oxygen runs out then the machine switches off so it is impossible to just deliver nitrous oxide
○ If gases fail then the valve opens to allow in room air into the circuit
If machine does turn off the patient still has the nasal hood on and can breathe through their mouth but it’s not nice to be given no air through the nasal hood so this valve will open and the patient will be able to continue to breathe room air through their nose instead

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10
Q

what is the oxygen flush button

A

○ Flushes oxygen 35 L / min
§ Push button and it will deliver very fast flowing oxygen
○ Emergency use only
§ Sometimes can be used to fill the reservoir bag if the patient has sucked all the air out of it and you’re trying to bring the patient round again
§ Pressing the button does cause the reservoir bag to expand
Silver button at very bottom

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11
Q

what is the reservoir bag

A
  • 2 or 3 L bag
    ○ Bag full of air or oxygen [For you to get the flow control right ie the litres per minute that the patient needs you are using the reservoir bag to help you]
  • Used to emulate the patients lungs
    Smaller bag available for children
  • The bag should move visibly with each inspiration and expiration
    ○ Want the bag to gently move in and out
    ○ If you haven’t given the patient enough gas to breathe in then the bag will flatten because you’ve sucked all the air out of it so then you can press on the flush button to fill it a bit again so the patient doesn’t feel like there is nothing coming
    ○ If the bag is very full like a balloon and doesn’t move then you are giving the patient too many litres per minute and they are not actually needing that much
  • Must not collapse
    Helps to monitor respiration
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12
Q

what are the gas delivery hoses

A
  • 2.5cm diameter, corrugated
    • Universal joints
    • One hose delivers fresh gases from machine
    • One hose delivers waste gases to scavenging system
      ○ Important that nitrous oxide is scavenged away and taken out of the atmosphere so that other people in the room aren’t starting to breathe it
    • Non return valve in expiratory limb prevents rebreathing expired gases
      Single use breathing circuits
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13
Q

what is the nasal mask / hood

A
  • Various sizes
    • Should form seal around patients nose
      ○ To ensure that the gases don’t escape
      Two connectors to breathing circuit
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14
Q

what is the scavenging system

A
  • Active scavenging of waste gases
    ○ Small negative pressure to ensure that the gases are sucked away
    • Changing surgery air reduces nitrous oxide levels
      ○ 15 changes of room air per hour
    • Watch for patient mouth breathing
      ○ Check mask seal to reduce contamination
      § Remind patient to continue to breathe in and out through their nose
      ○ If patient is mouth breathing then they are expelling the gases into the atmosphere rather than the scavenging system
      Use of rubber dam will decrease likelihood of mouth breathing
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15
Q

list the safety features

A
  • Air entrainment valve
  • Oxygen flush button
  • Oxygen monitor
    ○ Can see how much oxygen they are actually breathing
  • Reservoir bag
    ○ Emulate lungs to check breathing is correct
  • Colour coding
  • Scavenging system
  • Oxygen and nitrous oxide pressure dials
  • Pressure reducing valves
  • One way expiratory valve
    Quick fit connection for positive pressure oxygen delivery
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16
Q

what do the colour codes mean on the equipment

A

○ Blue tanks with nitrous oxide
○ Oxygen tanks are black

○ The pins that attach these to the machine mean that you can’t actually attach a blue nitrous oxide tank to the oxygen valve ie you cannot attach the wrong gas

17
Q

what are pressure reducing valves

A

○ Pressure dials on top of tank to tell you how much gas you have
○ Very essential to have a full tank (especially of oxygen) beside the tanks in use
○ If you are in the middle of sedating the patient and you can see the pressure falling in the oxygen tank, then you know you can just turn on the back tank
○ Should always have a full unopened tank of oxygen

18
Q

what are the advantages of IS

A
  • Rapid onset
    ○ 2-3 minutes
    • Rapid peak action
      ○ 3-5 minutes
    • Depth altered either way
    • Flexible duration
    • Rapid recovery
    • No injection
      ○ For the sedation but obviously LA still required depending on the procedure
    • Few side effects to patient
    • Drug not metabolised
      ○ Ie doesn’t have to go to the liver, doesn’t get turned into other things, doesn’t live in the body for hours, basically just blown back out through the lungs
    • Some analgesia
      ○ Though better for ischaemic than inflammatory pain
      ○ Get tingly hands / feet, mouth feelings tingly
    • No amnesia
      ○ Fear of unknown gone
      Potential to have treatment in the future without IS
19
Q

What are the disadvantages of IS

A
  • Equipment expensive
    • Gases expensive
    • Space occupying equipment
    • Not potent
      ○ For someone who just needs that final push to get a little courage to have the treatment
      ○ Needs to be a patient who wants the treatment
      ○ Will not work on someone who does not want the treatment
    • Requires ability to breathe through nose
    • Chronic exposure risk ?
      ○ Important to have scavenging to protect environment and staff
    • Staff addiction
    • Difficult to accurately determine actual dose
      ○ Silver ball is not always very accurate
      Depends on seal of nasal hood, how the patient breathes, etc
20
Q

What are the signs of adequate sedation

A
  • Patient relaxed / comfortable
    ○ Feel dreamy and floaty
    • Patient awake
    • Reduce blink rate
    • Laryngeal reflexes unaffected
    • Vital signs unaffected
    • Gag reflex obtunded
      ○ Reduced
    • Mouth open on request
    • Decreased reaction to painful stimuli
      ○ Eg LA injections
    • Decrease in spontaneous movements
      ○ Patient so relaxed cannot be bothered to move their arms and legs etc
      Verbal contact maintained
21
Q

what are the symptoms of adequate sedation

A
  • Mental and physical relaxation
    • Lessened awareness of pain
    • Paraesthesia
      ○ Lips
      ○ Fingers
      ○ Toes
      ○ Legs
      ○ Tongue
      ○ = tingling
    • Lethargy / “a few pints”
      ○ “why your mum is less grumpy after a glass of wine”
    • Euphoria
      ○ Feeling high and happy
    • Detachment ‘floating feeling’
      ○ Don’t feel like they’re in the room
    • Warmth
    • Altered awareness of passage of time
    • Dreaming
      Small controllable “fit of the giggles”
22
Q

what are the signs and symptoms of over sedation

A
  • Mouth closing repeatedly
    • Spontaneous mouth breathing
    • Nausea / vomiting
    • Irrational and sluggish responses
    • Decreased cooperation
    • Incoherent speech
    • Uncontrollable laughter, tears
    • Patient no longer enjoying the effects
      ○ Patient has sore head etc
    • LOC
      = loss of consciousness
23
Q

what are pre-op instructions that should be given to the patient before the appointment

A
  • Have a light meal before appointment
    ○ 1-2 hours before hand
    ○ Something simple
    • Take routine medicines as usual
    • Children accompanied by a competent adult
    • Adults accompanied at their first sedation appointment but afterwards they then may attend alone
    • Do not drink alcohol on day of appointment
    • Wear sensible clothing
    • Arrange care of children during and after your appointment
    • Plan to remain in clinic for up to 30 minutes after treatment
      Usually won’t be this length of time but warn patient just in case
24
Q

what is the IS technique

A
  • Set up machine
  • Select nasal hood
    ○ Record size in notes
  • Connect to hoses
  • Set mixture dial to 100% oxygen
  • Settle patient in dental chair
  • Reinforce explanations of procedure - Ie breathe through nose at all times
  • Set flow rate to 5-6L per minute
    ○ Still on 100% oxygen
    ○ Might reduce this for a small child, may increase this for a large man
  • Position hood on the patient’s nose
  • Encourage nasal breathing
  • Check reservoir bag movements
    ○ Small movements = check seal and look for mouth breathing +/- decrease the flow
    ○ Movement too great = increase flow rate
  • Patient to be comfortable with hood before proceeding - give them About 1 minute of just breathing oxygen
  • Ask patient to signal when they begin to feel different
  • Reduce oxygen by 10%
    = 90 oxygen 10 nitrous oxide
  • Wait 1 minute and repeat
  • After oxygen reaches 80% reduce by 5% per minute
  • Stop titration when patient is ready for treatment
    ie When patient tells you they are comfortable
  • Constant reassurance and hypnotic suggestion
    ○ Suggest that they feel comfortable and relaxed, tell them their limbs feel heavy and they cannot be bothered moving with a calm voice
  • Monitor for signs and symptoms of adequate sedation
  • Adjust levels of oxygen as required
  • Monitor the patient during dental treatment
25
Q

what do you do if the patient is under sedated

A

If under-sedated decrease oxygen in 5% increments until satisfactory sedation
Use the mixture dial to increase and decrease oxygen

26
Q

what do you do if the patient is over saturated

A

If patient is over-sedated increase oxygen in 5-10% increments until satisfactory sedation

27
Q

how is recovery carried out following IS treatment

A
  • Gradually increase oxygen by 10-20% per minute until 100% or can turn straight to 100%
    • Administer 100% oxygen for 2-3 minutes to prevent diffusion hypoxia
      ○ Diffusion hypoxia can occur with the administration of inadequate amounts of oxygen during or immediately after nitrous oxide anaesthesia
      ○ The Fink effect also known as diffusion anoxia or diffusion hypoxia or the third gas effect is a factor that influence the partial pressure of oxygen (PO2) within the alveolus
      ○ This is really a theoretical risk it does not happen as our equipment always delivers enough oxygen
    • Remove hood and turn gas flow off
    • Return patient to upright slowly, give praise and reassurance
      Ensure patient feels back to normal before getting off chair

BDS4 sedation symposium (7 decks)

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