Sedation and special care Flashcards
(26 cards)
Problems in providing dental treatment
- communication
- anxiety
- moving target
- perception or reality
- previous experience
Which are the common patient groups
- Involuntary movements
- Learning difficulties (congenital and acquired)
Congenital movement disorders?
- muscular dystrophy
- cerebral palsy
- MS
- parkinson’s disease
- huntingdon’s chorea
huntingdon’s chorea is a learning difficulty - can make sedation tricky
MD - breathing concerns with sedation
Acquired movement disorders?
Head injury
Congenital difficulties
Syndromic and non-syndromic
?
Acquired learning difficulties
- Trauma
- Infection
- CVA
- Alzheimer’s
considerations?
Assessment of patients with learning difficulties
- Will behavioural management be possible?
* many patients can be treated with TLC - Is pharmacological management needed?
- Sedation or GA or both
* patient understanding
* patient’s pain experience
considerations?
Assessment of patients with involuntary movements
- mental and physical status
- anxiety
- pain experience
Considerations for consent?
- no one else can give consent
- patient competent to consent, but can’t write
- not covered by legislation
- verbal consent document in notes
- Adult incapacity act (2000) Scotland
1. No one else can give consent for adult to have treatment
2. If not competient to give consent:
Medically qualified or appropriately trained dentists can complete form allowing treatment, lasts up to 36 months
Different techniques used for conscious sedation?
- inhalational (NiO)
- Intravenous (Medazolam)
- Oral (Medazolam)
- Transmucosal (Rectal, Intranasal, Sublingual)
What does your choice of sedation technique depend on?
- patient co-operation
- degree of anxiety
- dentistry required
- skills of the dental team
- patient’s previous experience
- facilities avaliable
- anaesthetist required?
patient co-operation - vital, need lots for inhalation
dentistry required - if v.invasive, IV as won’t remember it
patient’s previous experience - what sedation have they had before?
Advantages for inhalation sedation
- useful for anxiety relief
- rapid recovery
- flexible duration
Disadvantages of inhalation sedation
- keeping nasal hood in place
- less muscle relaxation
- coordination of nasal breathing when mouth open
Features of inhalational sedation
- safe technique
- nasal breathing when mouth open
- understanding behavioural management
- cooperation
Advantages of IV sedation
- good sedation
- less cooperation needed
- muscle relaxation
less cooperation needed although need to get a canula in
muscle relaxation - can stop involuntary movements
Disadvantages of IV sedation
- baseline readings
- IV cannulation required
- assessing sedation level
- behaviour during recovery
- efficacy swallowing
assessing sedation level - non-verbal v. challenging
efficacy swallowing - if they already can’t swallow this could be dangerous, ask how well they eat food
What are the different techniques for IV sedation
- Midazolam
- Propofol
- Multiple agent
Propofol - anaesthetic, pump is fast acting, turn off pump recovery quick
Multiple agent - deeper sedation, in UK can only do conscious sedation i.e verbal contact must be maintained
What safety measures have to be checked with sedation
- swallowing
- airway
- liver
- medication interactions
- ASA 1 or 2
swallowing and airway is vital
liver - essential for metabolism of drug
ASA complicated 2 or higher seen in hospital or specialist
Advantages of Oral/Transmucosal sedation
- avoid cannulation
- can make induction more pleasant
- better cooperation
- better future behaviour
Disadvantages of Oral/Transmucosal sedation
- baseline readings
- bitter taste/stinging
- lag time
- untitrateable
- difficulty in monitoring level of sedation
- behaviour in recovery
- takes 30 mins to work
- bolus dose (IV is better, more adjustable)
Intranasal - don’t need to wait for it to be absorved through the gut. More reliable and faster (around 7 mins)
How does oral sedation happen
midazolam 20mg, drink in front of dentist
What is used for transmucosal sedation
Atomiser (intranasal)
What are some outcomes of sedation
nb differing levels of cooperation
- all needed treatment carried out
- some treatment can be carried out (rest needs GA)
- Exam, scale and polish (rest needs GA)
- other treatments
Not always possible to do all the treatment you need to but that doesn’t mean it’s not worth doing. Might allow an exam to stop or justify GA.
Also possible to do other things e.g. take blood, cut toenails, haircut etc
Considerations for treatment planning
- pre-sedation exam may not be possible
- ability to cope
- complicated treatment? nb maintenance in future
- treat patient not the carer
- use sedation because of clinical need
