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4 - sedation > need to know > Flashcards

need to know Flashcards

1
Q

Ideal properties of IV sedation agent

A

Anxiolytic
Sedative as side effect
Quick onset
Quick recovery
Easy to administer
Low cost

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2
Q

How do benzodiazepines work on the NS?

A

Act on GABA receptors in CNS to enhance GABA effects
Prolongs the time for receptor repolarisation
Mimic the effect of glycine on receptors

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3
Q

CV effects of benzodiazepines

A

Decrease BP by muscle relaxation
This decreases vascular resistance
Increased HR due to baroreceptor reflex

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4
Q

Benzodiazepine drug reactions

A

CNS depressants - opioids
Erythromycin
Antihistamines
Alcohol

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5
Q

Side effects of benzodiazepines

A

Tolerance
Dependence
Sexual fantasy

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6
Q

Diazepam disadvantages

A

Pain on injection
Long elimination half life
Risk of rebound sedation
Unpredictable

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7
Q

Dose and pH of midazolam

A

5mg/ml
pH 3.5

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8
Q

Onset and elimination of midazolam

A

Rapid onset
90-150 minutes elimination

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9
Q

Sedation team

A

Operator/sedationist
Second sedation trained person eg dental nurse
Someone else in practice as a runner eg - receptionist
Patients escort present

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10
Q

Advantages of dorsum of hand

A

Accessible
Superficial and visible

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11
Q

Disadvantages of dorsum of hand

A

Poorly tethered
Affected by peripheral vascularisation so may need to warm hand up

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12
Q

How much midazolam administered

A

2mg bolus then 1mg increments every 60s until suitable level of sedation

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13
Q

Signs a sedated patient is ready to start treatment

A

They are willing to start
Verrill’s sign of ptosis
Eve’s sign - loss of motor coordination
Delayed response to commands

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14
Q

General max midazolam dose

A

7.5mg

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15
Q

How long is midazolam pt likely to be sedated

A

30-45 minutes

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16
Q

Recovery steps for IV sedation

A

Escort with pt
60 minutes after last increment of midazolam
Cannula removed before leaving
Ensure pt can walk unaided
Escort given POI

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17
Q

What to do if pt goes into respiratory depression

A

Talk to pt and shake them
Head tilt, chin lift, jaw thrust
Oxygen 2L/min via nasal cannulae
Oxygen, max can give via Hudson mask
Flumazenil
Call an ambulance

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18
Q

Flumazenil dose?

A

500mcg/5ml
Dose 200mcg (2ml) then 100mcg (1ml) every 60s until response is seen

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19
Q

Risk of flumazenil

A

Resedation

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20
Q

Elimination half life of flumazenil

A

50 minutes

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21
Q

Definition of conscious sedation

A

Pt is given a drug which depresses the CNS so verbal contact with the pt can be maintained throughout the period of sedation
The drugs and techniques used should carry a margin of safety wide enough to render loss of conscious unlikely

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22
Q

List 4 cannula complications

A

Venospasm
Extravascular injection
Intra-arterial injection
Haematoma

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23
Q

Venospasm

A

Disappearing vein syndrome
Vein collapse at attempted venepuncture

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24
Q

How to manage venospasm

A

Gets worse at repeated attempts
Slow skin puncture makes it worse - efficient technique
Ask pt to wear gloves or warm hands

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25
Extravascular injection
Active drug injected into interstitial space causing pain and swelling Can delay absorption
26
How to manage Extravascular injection
Prevention by good cannulation and test dose of saline Treat by removing cannula, applying pressure and reassuring pt
27
Signs of intra-arterial injection
Pain on injection Red blood in cannula Weakening pulse Pain radiating distally from site of cannulation
28
Avoid intra arterial injection
Avoid anatomically prone sites - antecubital fossa Palpate first
29
Manage intraarterial injection
Monitor for loss of pulse, limb cold and discoloured Leave cannula in situ 5 minutes post drug If no problems remove cannula If symptomatic leave cannula and refer to hospital
30
Haematoma
Extravasion of blood into soft tissues causing bruising Due to damage to vein walls Caused at venepuncture or removal of cannula
31
Haematoma prevention
Good cannulation technique Pressure post-op Take care with elderly
32
Haematoma tx
Time Rest Reassurance Ice pack then moist heat Heparin gel
33
Complications during sedation
Hyper-responders Hypo-responders Paradoxical reactions Oversedation Allergy
34
What is hyperrespondance and how to prevent
Deep sedation using minimal dose Use 1mg increments when titrating drug
35
Hyporespondance and management
Little sedative effect with large doses Check cannula is in vein
36
Types of tolerance
Benzodiazepine induced Cross tolerance Idiopathic
37
Threshold to abandon midazolam tx
10mg Can be up to 15 with specialists
38
Paradoxical reactions
Pt appears to sedate normally but reacts extremely to all stimuli
39
Paradoxical reaction tx
Relax pt when stimuli is removed Check for LA failure Reversal agent
40
Oversedation
A loss of consciousness Pt has respiratory depression and loses ability to maintain airway and undergoes respiratory arrest
41
Allergic reaction
Do not reverse - pt could be allergic to flumazenil as it is a benzodiazepine Manage anaphylaxis as if pt is not sedated
42
Complications of IS
Oversedation Patient panics
43
Signs and symptoms of nitrous oxide overdose
Pt discomfort Lack of cooperation Mouthbreathing Giggling Loss of consciousness Nausea Vomiting
44
nitrous oxide overdose management
Reduce nitrous oxide concentration by 5-10% Reassure pt Dont remove nosepiece - can cause diffusion hypoxia
45
Why is drug history important
Almost all drugs increase sedative effect of midazolam
46
ASA I
Normal healthy patient Non-smoker Minimal alcohol
47
ASA II
Mild systemic disease
48
ASA III
Severe systemic disease Limits capacity but not incapacitating
49
ASA IV
Severe systemic disease Constant threat to life
50
ASA V
Moribund Not expected to live >24 hours
51
ASA VI
Pt brain dead for organ donation
52
Where to treat each ASA class
ASA I and II - primary care ASA III and IV - secondary care
53
Pregnant woman ASA
II
54
Vital signs measured in sedation assessment
HR BP Oxygen saturation BMI
55
Methods of pain and anxiety management in children
NPBM LA Sedation GA
56
Aids to delivering LA to children
Behavioural management Hypnosis and relaxation techniques CBT Using the wand
57
Indications for IS in children
Age - must be able to sit in chair and breathe through nose with mouth open Mild/moderate anxiety Mild asthma Tx needed in multiple quadrants Good management of gag reflex
58
Contraindications to IS in children
Age - can’t understand concept or breathe through nose with mouth open High anxiety Nasal blockage Previous unsuccessful IS Intellectual impairment
59
Indications for IV sedation in children
Age around 12 - no hard age limit No/mild anxiety Helpful for asthma Previous difficult dental experiences High volume of tx needed
60
Contraindications for IV sedation in children
Age under 12 Anxiety/needle phobic Intellectual impairments If child likes to monitor the tx
61
General indications for IS
Anxiety Needle phobic Gagging Medical conditions aggravated by stress Unaccompanied adults requiring sedation
62
General contraindications for IS
Common cold Tonsillar enlargement Severe COPD First trimester of pregnancy Claustrophobia
63
Advantages of IS
Rapid onset Rapid peak action Flexible duration No amnesia Drug not metabolised
64
Disadvantages of IS
Expensive equipment Space occupying equipment Staff addiction Possible chronic exposure risk Difficult to determine actual dose
65
How nitrous oxide is administered
Ask pt to signal when they feel different Reduce oxygen by 10% Wait 1 minute and repeat After oxygen reaches 80% reduce by 5% per minute Stop titration when patient ready
66
How to adjust oxygen in IS
If under sedated decrease by 5% increments until satisfactory sedation If over sedated, increase oxygen in 5-10% increments until satisfactory sedation
67
How to take patient off IS sedation
Gradually increase O2 by 10-20% until 100% 100% O2 for 2-3 minutes to prevent diffusion hypoxia Remove hood and turn gas flow off Return pt to upright slowly, give praise and reassurance
68
Why is diffusion hypoxia a risk
Due to inadequate amount of O2 during or immediately after nitrous oxide administration Influences the partial pressure of O2 within the alveolus
69
Success rate of IS
50-90%
70
CBT
Brief psychological therapy - talking therapy Helps with a range of issues - anxiety, specific phobias Based on idea our thoughts, feelings and behaviours are all linked
71
Dental anxiety
General fear Occurs without a triggering stimulus Anticipatory due to previous negative experience
72
Dental fear
Intense biological response to immediate danger which is specific to
73
Dental phobia
Clinical mental disorder Debilitating fear 11% prevalence in UK
74
Components of CBT
Emotional Psychological Cognitive Behavioural
75
Disadvantage of antecubital fossa
Close to branchial artery and median nerve

4 - sedation (10 decks)

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