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Module 8 > Special care > Flashcards

Special care Flashcards

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1
Q

Which type of sedation provides anxiolytic effects and analgesics effects?

A

Nitrous oxide with oxygen (inhalation sedation)

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2
Q

What is entonox?

A

Another name for nitrous oxide/oxygen inhalation

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3
Q

What is the first stage of nitrous oxide delivery?

A

100% oxygen for 1-2 minutes at flow rate of 5-6 litres a minute

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4
Q

What is the maximum dose of nitrous oxide?

A

70% (30% minimum)

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5
Q

Which type of sedation is not metabolised by the kidney or liver?

A

nitrous oxide

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6
Q

Key contraindications of inhalation sedation

A

COPD
Pregnancy
Recent eye or ear surgery
Vitamin B12 deficiency (can already cause inactivation of this vitamin so this is more dangerous if there’s a deficiency)
Methotrexate interaction
Chemotherapy interaction

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7
Q

Diffusion hypoxia

A
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8
Q

How do we prevent diffusion hypoxia?

A

Administer 100% oxygen after cessation of nitrous oxide for 5 minutes to prevent this.

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9
Q

Signs of a nitrous oxide overdose?

A

Headache nausea vomiting

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10
Q

What social issue could be a barrier to someone getting IV sedation?

A

Lack of an escort :(

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11
Q

Contraindications of IV sedation

A

Needle phobic
Pregnant
Medical reasons (BMI, cardiac issues etc)
Social reasons (no escort :(…)
Poor venous access

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12
Q

What is a tourniquet?

A

Arm tightening strap to allow venous access

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13
Q

What titration of midazolam is used?

A

1mg per ml (5ml tube/ampoule)

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14
Q
A

A - Cephalic vein
B - Median Cubital Vein
C - Basilic vein

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15
Q

What cannula is used for IV sedation?

A

22G (wipe first w/chlorohexidene wipe!)

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16
Q

What do you need to observe to ensure you are in a vein?

A

primary flashback and then secondary flashback

THEN flush with saline

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17
Q

IV sedation… pain begins radiating down the forearm towards the fingers - what is happening?

A

Accidental entry into an artery (instead of a vein) STOP immediately

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18
Q

At what rate is midazolam administered?

A

Increments of 1mg given every 60 seconds.

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19
Q

What is the maximum dose of midazolam you can give?

A

10mg

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20
Q

What is a positive Eve’s sign and what does this mean?

A

Asking the patient to touch the tip of their nose with their finger with their eyes closed.
Difficultly or inability to perform this task indicates a positive Eve’s sign = higher level of sedation.

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21
Q

What do you do after you’ve finished administering the IV Midazolam?

A

Flush with saline

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22
Q

What could interfere with monitoring oxygen stats?

A

The pulse oximetry may not work effectively if the patient is wearing dark nail polish or acrylic nails.

Cold hands!! - get the patient to warm up their hands

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23
Q
A
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24
Q

What is normal oxygen saturation vs worrying oxygen saturation?

A

98% is normal
below 96% would require action to improve
below 90% is worrying (suggests respiratory distress - give oxygen!! via nasal cannula 2-4 litres a min)

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25
26
What would you do during IV sedation if the oxygen concentration wasn’t improving?
Administer the reversal agent Flumazenil Bag and mask ventilation AMBULANCE!
27
How much sedation time do you typically have to work with?
30-40 minutes
28
Why might access be difficult to do tx after IV sedation?
Muscle relaxation may mean you need to use a mouth prop to maintain mouth opening
29
What should patients make sure not to do after having IV sedation?
No… drinking alcohol driving operating machinery cooking boiling kettles signing important documents …for the rest of the day.
30
What are the rules about discharging patients after IV sedation?
At least one hour must have elapsed since the last increment of the drug was given before the patient can be discharged. NOTE: don’t remove the cannula until the patient is ready to be discharged/fully recovered Must have an escort.
31
What scoring system can be used to assess airways?
Mallampati score (based on uvula visualisation)
32
ASA
Assessment of medical fitness for sedation (grading I —> V)
33
ASA rating by blood pressure - cut off in general practice and DDH for sedation?
Normal BP = 120/70 ASA I = <140/90 General practice cut off = >160/95 DDH cut off = 170/100
34
35
BMI not ideal for sedation
>40
36
Oral sedation
Midazolam delivered as a drink (not very common)
37
Why is oral sedation not ideal for those with needle phobia?
You still must cannulate for safety incase you need to administer the reversal agent (Flumazenil)
38
What is an example of a premedication?
Diazepam (still a benzodiazepine)
39
How would a premedication be taken?
5-10mg of diazepam night before, wakening of the appointment and 60-90 minutes before the appointment.
40
What can diazepam interact with?
Antibacterials (i.e Rifampicin), antivirals (i.e. Ritonavir), Proton pump inhibitors (i.e. Omeprazole)
41
Aside from certain drug interactions, what are other contraindications of diazepam?
Hepatic impairment Renal impairment Pregnancy Breast feeding
42
Temazepam
An alternative premedication
43
What effects do benzodiazepines have?
Anxiolytic, anticonvulsant, sedative, amnesia, muscle relaxation. NOT analgesic effects.
44
Paradoxical reaction
When the opposite of the drug happens… i.e. pain awareness increase, anxiety increases etc.
45
What resources could you use for sedation guidance?
Intercollegiate advisory committee for sedation in dentistry standards and SDCEP third edition
46
47
What is an important part of gaining consent in sedation?
IT HAS TO BE WRITTEN. Consent to the sedation, the LA and dentistry.
48
What if the sedated patient is drowsy and tells you they don’t want treatment?
A patient who is sedated remains in charge of his/her treatment. Forced treatment is assault.
49
50
Definition of GA
Controlled unconsciousness
51
What type of sedation needs “open consent” and what is this?
GA Essentially preparing for the fact that more treatment than anticipated may be necessary (i.e. attempted RCT but actually tooth needs XLA).
52
Why can GAs not be completed in DDH?
In 1998, paeds patient died. Since 2001, all GAs could only be administered in hospital with intensive care facilities for support.
53
How long does it take for Midazolam to flow from the hand - heart - brain?
25 seconds
54
How is midazolam recovered from?
1. Redistribution (into the fat) 2. Metabolism (by the liver) and then elimination (by the kidneys).
55
Alpha half-life
This refers to the initial recovery = the time taken for the serum concentration to drop by 50% (redistribution).
56
Beta half life
Elimination = the time take to remove half the drug from the body.
57
What is the alpha half-life of midazolam?
2 hours (hence tx in this window)
58
Pharmacodynamics vs pharmacokinetics
Dynamics = what the drug does to the body Kinetics = what the body does to the drug
59
If all benzodiazepines are pharmacodynamically the same, what are the differences between some of them i.e. Diazepam and Midazolam?
Differences in potency due to affinities for receptors. Half life Active metabolites
60
What is the resting membrane potential of an inactive/resting neuron?
-70mV
61
What happens when an action potential is triggered?
62
What receptor does benzodiazepine act on and what does this do?
GABAa receptor - this allows the flow of more chloride ions into the neuron making the resting membrane potential more negative and thus making it harder for an action potential to be fired.
63
What is the mode of action of nitrous oxide?
Not fully understood but essentially enhances GABA activity allowing more chloride ions into the neuron (similar to midazolam)
64
What’s the desired level of nitrous oxide?
20-50% nitrous oxide mixed with oxygen.
65
What is the half life of diazepam?
30 hours.
66
Why can diazepam not be used IV?
Made with organic solvent (propylene glycol), caused vein damage, pain and skin ulceration.
67
How is does midazolam act upon the body?
Originally water soluble, once metabolised by the liver it produces the active metabolite (alpha-hydroxymidazolam) now lipid-soluble it is able to penetrate the blood-brain barrier.
68
How much more potent is midazolam compared with diazepam?
Two and a half times more potent.
69
What medical condition may cause a patient to have a longer effect of the drug?
Liver dysfunction (less able to metabolise the drug prolonging the half-life)
70
Main drug interactions of benzodiazepines?
Opioids (respiratory depression, sedation and hypotension) Propofol (respiratory depression and hypotension)
71
Drug interaction of nitrous oxide
opioids (respiratory depression and hypotension)
72
How does grapefruit juice effect benzodiazepines?
Increases the level of it in the blood.
73
How does st john’s worts effect benzodiazepines in the blood?
Reduces the effect of it
74
How does flumazenil work?
It acts as a reversal agent as it has a higher affinity for the benzodiazepine reception than virtually all know active drugs.
75
What are two key medical history considerations for benzodiazepine use?
Avoid in pregnancy Avoid in hepatic/renal impairment
76
Verill’s sign
eyelids dropping

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