Flashcards in Intravenous sedation Deck (61)
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1
Advantages of IV sedation
Given remote from operating site
Administered as single dose
Rapid onset
Mouth breathing not important
Pt co-operation less important
***
2
Disadvantages of IV sedation (6)
Not clinically useful analgesia
Overdose can lead to profound respiratory depression
Laryngeal reflexes obtunded for a short period?
Occasional disinhibition effects
Occurrence of sexual fatasies
Pre/ post op instructions must be followed
3
Pt management techniques (9)
Time and TLC
Local analgesia
Psychotherapy
Hypnosis
Acupuncture
Inhalation sedation
Oral/ transmucal sedation
IV sedation
GA
4
Minimising anxiety (7)
Empathy
Kindness
Courtesy
Explanation
Support
Time
Gentleness
5
Purpose of sedation (5)
Control of fear, anxiety and apprehension
Reduce stress associated with unpleasant/painful procedures
To control severe gag reflexes
Treatment of uncooperative patients, including children and those with disability
To stabilise the blood pressure of patients with hypertension and a history of cardiovascular cerebro-vascular disease
6
Medical history (5)
Written questionnaire completed with the patient
Verbal discussion with patient
Contact GP
Liaise with other health care professionals
Advice from consultants
7
American Society of Anaesthesiologists Physical Status Rating (5)
I
II
II
IV
V A moribund pt not expected to live 24hrs
****
8
Dental history (5)
Attitude to dental care
Past history
Past experience of sedation and GA
Recent history
Main dental problem
9
Dental examination (7)
Tx required
Length of procedure
Degree of trauma involved
Muliple visits
Acute infection
Degree of pt co-operation required
Radiographs required during tx
10
Social history (7)
Able to provide a responsible escort
Ability to understand and follow pre- and post-operative instructions
Someone to help at home
Able to take time off work
Someone to look after the children
Someone to stay overnight
Transport to and from the surgery
11
Consent (2)
Informed consent explains the benefits of treatment, the risks and disadvantages of treatment and the treatment alternatives to the patient in a language that they understand. Document for each course of treatment
12
Patients who lack capacity to give informed consent (6)
Discuss everything with next of kin; discuss treatment with care staff, appoint IMCA
Have 2 professionals (doctor/ dentist) independently agree that this treatment is in the best interests of the patient.
Named person to sign pre/post operative instructions
Liaise with parents/GP regarding medical history
13
Baseline physical assessment (7)
Colour
Pulse
Respiration
Arterial oxygen saturation
Blood pressure
Weight
BMI
Level of consciousness
Degree of understanding and co-operation
14
Special tests e.g. (3)
Liver function test
ECG
Sickle cell test
15
Contraindications to IV sedation (6)
Allergy to benzodiazepines
Pregnancy
Age
ASA III, IV, V
Poor veins
Drug interactions
16
Equipment (6)
Oxygen and emergency oxygen
Cylinder capable of giving 15l/ min
Attachments capable of administering IPPV
Within 'arms reach'
Checked each session
Records kept
17
Suction (3)
Emergency suction
Non-mains powered suction
Attachments for oral and pharyngeal suction
18
Emergency drugs (3)
Flumazenil (Anexate) 0.5mg/5ml, and appropriate emergency drugs
Needles, syringes, cannula, tourniquet, tape, alcohol wipe
Staff trained and confident to use them
19
Other appropriate emergency drugs (2)
Midazolam 10mg/5ml
Saline for IV administratin
20
Clinical effects of benzodiazepines (6)
Anxiolysis
Sedation
Hypnosis
Amnesia
Anticonvulsant
Decrease in skeletal muscle tone
21
Set up for IV sedation
Midazolam, note expiry date/batch, 5ml syringe, straight needle for drawing up drug, pre injection swap/mediwipes, micropore tape, 22G cannula, gauze/ampoule opener, yellow sharps box, tourniquet
22
Normal values
Weight: 70kg,
Temperature: 36-37.5C 96.8-99.4F,
Colour: pink, well perfused,
Pulse: 70 beats per minute, full volume, regular,
Respiration: 12-20 regular breaths per minute
Blood pressure: 120/80 mm Hg 16/10 KPa
23
Colour
Pink, well perfused. Blue, cyanosed, check nailbeds, earlobes, lips, gingivae
24
Respiratory obstruction
Potentially fatal complication, may lead to coughing, straining, vomiting and regurgitation, suspected if snoring, paradoxical chest and abdominal movement, straining. Airway causes (edentulous patients), tongue, swelling, tumour, stricture, irradiation, epiglottis, restricted jaw opening
25
Level of consciousness
Stand unaided with eyes closed, Romberg test, touch nose with forefinger, loss of facial expression/animated, eyes open/closed/ptosis, speech slurred/slow, respond to verbal command
26
Pulse oximetry based on 3 principles (3)
• The difference in absorption spectra of reduced and oxygenated haemoglobin
• The Beer-Lambert Law
• That only reduced and oxy-haemoglobin are present in the blood
27
Paperwork (4)
Consent, medical history, signed pre and post operative instructions, sedation record sheet
28
Second appropriate person (1)
BADN Registered Dental Nurse with Certificate in Dental Sedation Nursing
29
Blood pressure (5)
Manual sphygmomanometer, electronic sphygmomanometer,
Pre-operative, intra-operative, post-operative
30
Choice of IV sedating agent - historical and nowadays (3)
Diazepam 1966 historical
Midazolam 1984 - quick onset of action and rapid metabolism and excretion
Additional drugs - multidrug sedation - propofol and opiates require advanced airway management training
31
Midazolam for injection (3)
Clear, colourless isotonic solution
containing
-sodium chloride
-hydrochloric acid
-sodium hydroxide
-in water for injection
pH 3.3
Lipid soluble at physiological pH
32
CNS - BZD receptors (1)
Benzodiazepines enhance inhibitory action of GABA in the CNS
33
Midazolam - site of action (2)
BZD potentiate GABA by increasing the flux of Cl ions into the cell, thus decreasing the ability of the cell to initiate an action potential.
34
GABA - inhibitory neurotransmitter (2)
GABA - A modulated by other receptors
-benzodiazepines
-barbiturates
-some steroids
-alcohol
GABA - B skeletal muscle role
35
GABA - A modulation (6)
Opening of receptor channels (Cl influx)
Anxiolytic effect
Hypnotic sedative
Anticonvulsive
Amnestic effect
Muscular relaxation
36
Midazolam - pharmacokinetics (2)
Elimination half life 1-2.8hrs
Onset of action:
IV *3 minutes
IM 5 minutes
Oral 15 minutes
Nasal 15 minutes
Rectal 15minutes
37
Increased Midazolam availability (3)
Factors increasing half life:
age ( elderly)
sepsis
poor renal function
38
Midazolam - additional effects (3)
Decreases ventilatory response to CO2
Decreases mean arterial pressure
Reduction of cerebral blood flow
39
Midazolam contraindications (4)
Hypersensitivity to BZP
Myasthenia Gravis
Shock or vital sign depression
Acute narrow angle glaucoma
- open angle glaucoma with app. Rx
- ask treating physician
40
Midazolam care (5)
BZP use
Opiates
Alcohol abuse
other sedatives
Social drugs
41
Signs of midazolam overdose (5)
over sedation
confusion
impaired coordination
diminished reflexes
decreasing vital signs/O2 sats
42
What to do in a midazolam overdose (3)
Stop Midazolam
Oxygen
Reversal - Flumazanil 200ug in intial dose
43
Flumazenil - pharmacokinetics (3)
Dose: 200-600ug IV
Competitive inhibitor of BZP
Elimination half life 53 minutes
Potential for re-sedation due to differences in half life
44
Patient preparation (4)
Pre assessed - Baseline observations
MH inc allergies and drugs noted
(ASA assessment)
Written consent - treatment checked
Escort/ transport/ childcare etc checked
45
Venepuncture (2)
IV access gained
- practice/ cannula knowledge
IA access - accidental
-pre drug admin: remove cannula - apply P
-post drug admin: leave cannula in place and
contact local vascular surgeons urgently
46
Watch for which 3 things (3)
TRANSFIXATION
HAEMATOMA
EMBOLISM
47
Types of embolism (3)
Thromboembolism
Cannula embolism
Air embolism
48
Monitoring (4)
BP, HR and O2 Saturation
BP required Pre and Post treatment can be continuously monitored
O2 Saturation required throughout
Observation of patient - Vital signs
49
Supplemental oxygen - always consider (5)
Epilepsy
IHD
Previous CVA
Heart Failure
Anaemia/Sickle cell trait
50
Operator behaviour (3)
Behaviour to induce confidence/relaxation
Quieten voices
Appropriate language
*Always have operator and additional trained person in room - record this
51
Preparation of IV drugs (4)
NPSA guidelines on preparation and administration of drugs for injection
Sterility
Labelling
Disposal
Recording
52
Local anaesthetic in sedation (2)
Midazolam has no analgesic properties
LA is required
-however suggestion can be powerful
53
Midazolam titration (3)
Slow IV administration of 2mg
Wait 90 seconds assess sedation
1mg
Wait 90 seconds assess sedation
1mg …
until desired sedation achieved
54
Midazolam sedation (3)
Golden 20 minutes
Another 30 minutes possible
May require top ups
Realistic treatment in time
Dose range 2-10 mg usual
55
Complications (4)
Falling sats
Under sedated
Over sedated
Venepuncture related
-failed
-bruising
-extravasation
56
Recovery and discharge (5)
Monitor whilst recovering
Keep one hour after last IV dose of midazolam
Written and verbal post -op instructions to escort
Rhomberg
Steady on feet/walk unaided
57
Additional post-op instructions - for 24 hours (4)
No driving/operating machinery inc. cooking, ironing
No alcohol/sedative drugs
No legal responsibilities inc. signing legal documents, looking after children, attending work
Patient not to be left alone
58
Recording (5)
Keep accurate contemporaneous notes
Have a log of all medications used
Dispose of unused Midazolam properly and witnessed
Record any flumazanil use
Regularly check drugs -exp dates
59
Regular training/ checks (3)
All Resus drugs/equip checks
Staff training resus/emergencies
Have these logged within the practice
60
Unusual side effects (1)
Sexual fantasy is thought to occur in 1 in 200 cases of midazolam sedation
61
