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1 - BDS4 finals - big topics > Sedation > Flashcards

Sedation Flashcards

1
Q

midazolam preparation

A

5mg/5ml

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2
Q

midazolam is metabolised in….

A

the liver

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3
Q

midazolam half life

A

90-150 mins

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4
Q

how to treat midazolam over sedation

A

Flumanezil
500mcg in 5ml

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5
Q

flumazenil dose

A

200mcg then 100mcg increments every 60 seconds until a response is seen

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6
Q

fumazenil downsides

A

shorter half life than midazolam
- 50 mins
risk of re-sedation

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7
Q

over sedation - signs and symptoms

A

loss of responsiveness
respiratory depression
loss of ability to maintain airway
respiratory arrest

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8
Q

management of respiratory depression

A

check oximeter
stimulate patient
- ask them to breathe
supplemental oxygen
- nasal cannula 2 litres per minute
reverse with flumazenil

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9
Q

Effects of benzodiazepines

A

respiratory depression
- CNS depression and muscle relaxation
reduced blood pressure by muscle relaxation decreasing vascular resistance
- increase heart rate due to baroreceptor reflex

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10
Q

benzodiazepines side effects

A

drug interactions
- other CNS depressants
- erythromycin
- antihistamines
tolerance
dependence
sexual fantasies

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11
Q

IV sedation procedure

A

cannulation
pulse oximeter
BP monitoring
drug administration
- 2mg bolus
- 1mg increments every 60 seconds
- until suitable level of sedation

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12
Q

iv sedation - signs patient is adequately sedated

A

slurring and slowing of speech
relaxed
delayed response to commands
willingness to accept treatment

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13
Q

ASA I

A

normal healthy patient
non-smoker
minimal alcohol
may be treated in primary care

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14
Q

ASA II

A

mild systemic disease
may be treated in primary care

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15
Q

ASA III

A

Severe systemic disease
- limits activity but not incapacitating
should be treated in secondary care

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16
Q

ASA IV

A

severe systemic disease; constant threat to life
must be treated in secondary care

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17
Q

ASA II examples

A

current smoker
pregnancy
well controlled diabetes
obesity

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18
Q

ASA III examples

A

insulin dependent diabetic
stable angina
morbid obesity BMI >40

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19
Q

ASA IV examples

A

Severe COPD
BP > 200/115
unstable angina

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20
Q

When can the patient leave following procedure?

A

60 minutes following last increment

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21
Q

what must you do before patient leaves the surgery following treatment?

A

remove canula
ensure patient can walk unaided
give written post op instructions to escort

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22
Q

Iv sedation pre-op instructions

A

do not smoke 24 hours prior
no alcohol or recreational drugs 48 hours prior
avoid tablets that may cause drowsiness
do not eat or drink within 2 hours before appointment - eat a light meal at least 4 hours before
must be accompanied by a responsible adult - advisable to go home in a car or taxi
arrange suitable childcare for 24 hours after appointment
do not drive to appointment

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23
Q

iv sedation post op instructions

A

no breast-feeding for 24 hours
should be taken home by escort
avoid public transport
avoid going out alone, no driving or operating machinery for 24 hours
do not smoke or drink alcohol for 24 hours
do not work for 24 hours

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24
Q

inhalation sedation contraindications

A

common cold
tonsillar enlargement
severe COPD
first trimester of pregnancy
fear of “mask”/claustrophobia
patients with limited ability to understand
obstruction of operative field by mask

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25
Equipment used in Inhalation sedation
gas cylinders pressure reducing valves flow control meter reservoir bag gas delivery hoses nasal hood waste gas scavenger system
26
how are waste gases scavenged in inhalation sedation?
active scavenging of waste gases with a small negative pressure
27
how to reduce the likelihood of the patient mouth breathing during inhalation sedation
use rubber dam
28
Inhalation sedation safety features
pin index system - prevents wrong cylinder being attached diameter index system - prevents cross infection of piping minimum oxygen delivery 30% oxygen fail safe - operates when oxygen pressure falls below 40psi air entrapment valve oxygen flush button oxygen monitor scavenging system one way expiratory valve presssure reducing valves
29
inhalation sedation advantages
rapid onset - 2-3 mins rapid peak action - 3-5 mins flexible duration rapid recovery no injection (for the sedation) few side effects drug not metabolised some analgesia no amnesia
30
inhalation sedation disadvantages
equipment expensive gases expensive space occupying equipment environmental concerns requires ability to breath through nose staff addiction difficult to accurately determine actual dose potential chronic exposure risk
31
inhalation sedation - signs of adequate sedation
patient relaxed patient awake reduced blink rate vital signs unaffected laryngeal reflexes unaffected gag reflex reduced decreased reaction to painful stimuli decrease in spontaneous movements verbal contact maintained
32
symptoms of adequate sedation
mental and physical relaxation lessened awareness of pain paraestheisa euphoria lethargy detached, floating feeling warmth altered awareness of the passage of time dreaming small controllable "fit of the giggles"
33
signs and symptoms of oversedation in inhalation sedation
mouth closing repeatedly spontaneous mouth breathing nausea/vomiting decreased cooperation incoherent speech uncontrollable laughter patient no longer enjoying effects loss of consciousness
34
inhalation sedation pre operative instructions
have a light meal before appointment take routine medicines as usual children accompanied by competent adult adults accompanied at first sedation appointment - afterwards may attend alone do not drink alcohol on day of appointment wear sensible clothing arrange for care of children during and after appointment plan to remain in clinic for at least 30 minutes after treatment
35
inhalation sedation technique (up to positioning the hood)
set up machine select nasal hood and record size connect to hoses set mixture dial to 100% Oxygen settle patient in dental chair reinforce explanations of procedure set flow to 5-6L per minute position hood on patients nose encourage nasal breathing check reservoir bag movements
36
inhalation technique once hood is positioned
allow patient to be comfortable with hood - about 1 minute ask patient to signal when they begin to feel different reduce 02 by 10% - wait 1 min and repeat once oxygen reaches 80% reduce by 5% a minute stop titration when patient ready for treatment
37
inhalation sedation - what must you do during the treatment?
constant reassurance monitor for signs and symptoms for adequate sedation monitor patient during treatment adjust oxygen level as required
38
inhalation sedation - over sedation management
increase oxygen. by 5-10% increments until satisfactory sedation
39
what to do if patient is under-sedated in inhalation sedation
increase oxygen in 5% increments until satisfactory sedation
40
inhalation sedation - recovery (following tx)
gradually increase oxygen by 10-20% per minute until 100% - can turn straight to 100% administer 100% oxygen for 2-3 minutes - to prevent diffusion hypoxia (Fink effect - theoretical risk) remove hood and turn gas flow off return patient to upright slowly, give praise and reassurance
41
inhalation sedation success rate
published data states 50-90%
42
Inhalation sedation has greater success with...
orthodontic extractions
43
inhalation sedation has poorer success in...
patients with pain
44
intravenous sedation cannulation complications
venospasm extravascular injection intra-arterial injection haematoma fainting
45
What is venospasm?
disappearing vein syndrome veins collapse at attempted venepuncture may be accompanied by burning associated with poorly visible veins
46
venospasm prevention
efficient technique warm water/gloves in winter
47
what is an extravascular injection?
active drug placed into interstitial space
48
extravascular injection symptoms and potential problems
pain swelling may cause delayed absorption of drug
49
extravascular injection prevention
good cannulation test dose of saline
50
extravascular injection treament
remove cannula apply pressure reassure patient
51
intra-arterial injection signs
pain on venepuncture difficult to prevent leaks pain radiating distally from site of cannulation loss of colour of warmth to limb/weakenening pulse
52
prevention of an intra-arterial injection
avoid anatomically prone sites palpate before attack
53
intra-arterial injection management
monitor for loss of pulse leave cannula in situ for 5 minutes post drug - if no problems = remove - if symptomatic leave and refer to hospital
54
what is a haematoma? how can it occur during iv sedation
extravasation of blood into soft tissues, due to damage to vein walls can occur at venepuncture due to poor technique can occur during cannula removal - failure to apply pressure
55
how to avoid haematoma in iv sedation
good cannulation technique pressure post operative - from operator not patient take care with elderly patients
56
haematoma treatment
time rest reassurance if severe - initial ice pack - moist heat - consider heparin containing gel
57
why might a patient faint during venepuncture?
starved anxiety related to venepuncture
58
how to avoid patient fainting?
don't starve patient topical skin anaesthesia position patient correctly
59
intravenous sedation complications of drug administration
hyper-responders hypo-responders paradoxical reactions oversedation allergic reasctions
60
Hyper repsonder - prevention
take care with titration - slow titration in elderly
61
Hypo responder - management and considerations
check cannula in vein may be due to tolerance - BZD induced - cross tolerance - idiopathic
62
What is meant by "paradoxical reactions" in relation to intravenous sedation?
appears to sedate normally reacts extremely to all stimuli - relaxed when stimuli removed
63
paradoxical reaction management
check for failure of LA find other management techniques watch immature teenagers
64
over sedation management
stop procedure try to rouse patient ABC if no response to stimulation and support - reverse with flumazenil 200ug then 100ug increments at minute intervals - watch patient for 1-4 hours
65
management of respiratory arrest
stimulate patient assess consciousness clear or maintain airway ventilate patent reverse sedation consider other medical incident
66
inhalation sedation potential complications
over sedation patient panics
67
signs and symptoms of nitrous oxide overdose
patient discomfort lack of co-operation mouthbreathing giggling nausea vomiting loss of consciousness

1 - BDS4 finals - big topics (17 decks)

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