Conscious Sedation
Dr. Rahaf Al-Habbab BDS. MsD. DABOMS
Diplomat of the American Boards of Oral and Maxillofacial
Surgery
Why Do Most People Avoid Going To The
Dentist?
FEAR
Office Anesthesia
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To facilitate surgery and patient comfort
Amnesia
Analgesia
Conscious Sedation
Ambulatory General Anesthesia (No Intubation)
Hypnosis
Immobilization
Ambulatory General Anesthesia
Selective use of sedative and anesthetic agents designed to
produce a brief period of anesthesia and to facilitate a rapid
recovery period after the termination of the procedure
• Patient has a brief post-operative recovery period
• Patient can ambulate after the termination of anesthesia
IV Sedation
A 30 year-old male patient, comes to your office for
consultation for extraction of hi maxillary and mandibular
third molars, He asked to be sedated.
How will you assess this patient?
Pre-Operative Evaluation
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PMH
Medication, Allergies
ASA Classification
Vital Signs: BP, Pulse, RR, Oxygen Saturation, Height, Weight
Physical Exam
Airway Exam
Pre-Operative Evaluation
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PMH
Medication, Allergies
ASA Classification
Vital Signs: BP, Pulse, RR, Oxygen Saturation, Height, Weight
Physical Exam
Airway Exam
ASA Classification
General Pre-Anesthetic Evaluation American Society of
Anesthesiologists (ASA) Physical Status Classes
ASA I
ASA II
A normal healthy patient
A patient with mild systemic disease or significant health
risk factor
ASA III A patient with severe systemic disease that is not
incapacitating
ASA IV A patient with sever systemic disease that is a constant
threat to life
ASA V A patient who is not expected to survive without the
operation
ASA VI A declared brain dead patient whose organs are being
Removed for donor purposes
Pre-Operative Evaluation
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PMH
Medication, Allergies
ASA Classification
Vital Signs: BP, Pulse, RR, Oxygen Saturation, Height, Weight
Physical Exam
Airway Exam
Pre-Operative Evaluation
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PMH
Medication, Allergies
ASA Classification
Vital Signs: BP, Pulse, RR, Oxygen Saturation, Height, Weight
Physical Exam
Airway Exam
Airway
Mallampati Classification
Airway
Class I
Facial pillars, soft
palate, and uvula are
visible
Airway
Class II
Facial pillars, soft
palate, and part of the
uvula
Airway
Class III
Soft Palate, and Base
of Uvula
Airway
Class IV
Only soft palate is
visible
Intubation is predicted
to be difficult
Airway
Airway Evaluation
Thyromental distance
not less than 3-4
finger width
Airway
Predictors of a difficult Airway:
• Obesity
• Mouth opening
• Thyromental distance
• Mental-hyoid distance
• Retrognathia
Pre-operative Instructions
Why “NPO” Guidelines?
• To avoid aspiration pneumonia
• To prevent foreign body obstruction
NPO Guidelines
Guidelines for pre-operative fasting
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No solids on day of surgery
Solids: 6—8 hours prior to surgery
Clear liquids: 2 hours prior to surgery
Oral Medications: 1 hour with sip of water
Equipments
IV Puncture
Butterfly Needles:
• Short metal needle
• Easy to place
• Winged tabs permit easy
securing point
• Short needle reduces
patient anxiety
IV Puncture
Angiocatheter
• Indwelling peripheral
catheter
• Catheter over needle
• Needle serve as an
introducer
• Variable length and gauges
of needles
IV Fluids
• IV Fluids provide hydration
• Administration of
anesthetic agents and
emergency medication
IV Fluids
Choose what you need and need what you choose
IV Puncture
The preferred site is:
Antecubital fossa
Brachial Artery
Other Sites: Hand, leg, neck
The hand is painful and some
drugs cause burning
(e.g. diazepam, propafol)
Monitoring
•BP
•HR
•Pulse
Oximetry
•RR
•3 Lead ECG
•End Tidal
CO2
Monitoring
Definition: continuous
observation of data to
evaluate physiologic
Function
Purpose: To permit prompt
recognition of a deviation
From normal, so corrective
therapy can be
implemented before
morbidity ensures.
Monitoring
Respiratory Monitoring
1- Oxygen Monitoring
• Pulse Oximetry
Monitoring
2- Ventilatory Monitoring:
• Visual inspection
(see the chest rise)
• Pretracheal Stethoscope
(precordial)
• End-tidal CO2
Second Part
Drugs
Drugs
•No drug ever exerts a single action
•No clinically useful drug is entirely devoid of
toxicity
Drugs
Ideal anesthetic agents for ambulatory general anesthesia:
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Rapid onset
Short duration of clinical effect
High clearance rate
Minimal tendency for drug accumulation
Benzodiazepines
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Most commonly used
Oral, IV, IM
The patient maintains his own reflexes
May cause respiratory depression in very large doses
Effects:
• Sedation
• Anxiolysis
• Antigrade amnesia
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Diazepam (VALIUM)
Midazolam (VERSED)
Reversal: Flumazenil
Opioids
Alter the sensation and suppress responses associated with certain
manipulation (such as elevation of a tooth), which persist despite
achievement of a profound nerve block
Effects:
• Analgesia
Types:
• Fentanyl
• Mepridine
• Morphine
• Reversal Naloxon (Narcan)
Anesthetic Agents
Propofol
• Dose dependant depression of the
central nervous system that give
rise to anesthetic effect that
ranges from sedation to hypnosis
• Short acting
• Widely used in ambulatory
general anesthesia
Anesthetic Agents
Ketamine
• A dissociative anesthetic
• Pharmacological immobilization
“chemical straight-jacket”
• Used as an adjunct to general
anesthesia
Guedel’s Classification
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Stage of Analgesia
Stage of Delirium
Stage of Surgical Anesthesia
Respiratory Paralysis
Guedel’s Classification
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Stage of Analgesia
Stage of Delirium
Stage of Surgical Anesthesia
Respiratory Paralysis
Guedel’s Classification
Stage I: Analgesia
• Patient is wake and conscious but remains under the drug
influence
• Respiration, eye movement and all protective reflexes are
intact
• Patient will be ideally calm and cooperative
• Light sedation
Guedel’s Classification
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Stage of Analgesia
Stage of Delirium
Stage of Surgical Anesthesia
Respiratory Paralysis
Guedel’s Classification
Stage II: Delirium
• CNS Depression is more pronounced
• Patient may briefly lose consciousness
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Respiration may be irregular in early stage II
Pupils reactive to light
Increased skeletal muscle tone/activity
Laryngeal and pharyngeal reflexes increased
• Entry into stage II is undesirable
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Patients will likely be hyper-responsive and difficult to manage
• During induction, stage II is typically bypassed
C
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Guedel’s Classification
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Stage of Analgesia
Stage of Delirium
Stage of Surgical Anesthesia
Respiratory Paralysis
Guedel’s Classification
Stage III: Surgical Anesthesia
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Desired level of anesthesia for major surgical procedures
Patient unconscious
No response to surgical stimulus (abdominal skin incision)
Respiration regular (autonomic and involuntary)
Alteration in muscle tone (relaxation)
Stage III is characterized by division into several (continuous) planes
of anesthesia
Differences related to variance in:
• Respiration
• Eyeball movement
• Reflexes
• Papillary constriction
Stage III: Surgical Anesthesia
Not an appropriate level of anesthesia for office setting
• Requires continuous respiratory support/ventilation
• No protective reflexes
Patient will be unresponsive and unarousable
• Potential for airway obstruction
• Inability to react to adverse events
Potential exists to slide into stage IV with few outwardly
visible signs unless carefully monitored
Guedel’s Classification
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Stage of Analgesia
Stage of Delirium
Stage of Surgical Anesthesia
Respiratory Paralysis
Stage IV: Respiratory Paralysis
• OK- NOW YOU ARE IN TROUBLE
• Onset of medullary depression
• Result in degradation of autonomic functions
• Begins with the onset of Respiratory Arrest
• Ends with Cardiovascular Collapse (late)
Conscious Sedation
• The patient maintain all reflexes
• The patient can respond to verbal command
• Drugs are titrated to effect
Ambulatory General Anesthesia
• Diazepam or Midazolam
• Fentanyl
• Propofol
• +/- Kitamine
Pediatric Cases
• Nitrous Oxide
Or
• Oral Midazolam
Or
• IM Ketamine
The End