Intravenous Sedation Monitoring 59 AMDG/Dental Squadron Technician Orientation Module

Training Objectives Verification of current BLS training Use of automated monitoring equipment Physiologic norms and overview of medications Overview of medical emergencies “Code Blue” procedures and “Crash Cart” familiarization

Levels of Anesthesia Local anesthesia Conscious Sedation Deep Sedation General Anesthesia

Local Anesthesia Elimination of sensations, particularly pain, by the administration of a topical application or regional administration or injection of a drug

Conscious Sedation A minimally depressed level of consciousness which allows the patient to independently and continuously maintain a patent airway and respond appropriately to verbal commands –Anxiolysis –Moderate Sedation

Deep Sedation A controlled state of depressed consciousness accompanied by a partial loss of protective reflexes and the ability to respond appropriately to verbal commands

General Anesthesia The elimination of all sensation accompanied by the loss of consciousness

Stages of General Anesthesia Stage I –Analgesia Stage II –Delirium Stage III –Surgical anesthesia 4 planes of surgical anesthesia

Stages of General Anesthesia Stage IV –Medullary paralysis

Level of Anesthesia In the OMFS clinic, Dunn Dental Clinic and MacKown Dental Clinic ….. –Stage I Otherwise known as “Conscious Sedation” In the Wilford Hall Medical Center OSOR –Stage III “Deep Sedation” General Anesthesia

Provider Training Must be able to safely manage 1 level of anesthesia beyond plane to be achieved –If practicing Deep Sedation you must be able to manage general anesthesia

Technician Responsibilities Pre-Procedure –Equipment Instruments Venipuncture Monitors Emergency Supplies –“Crash Cart” –Cardiac Monitor –Medications

Technician Responsibilities Pre-Procedure Patient Assessment –Vital Signs –Allergies –Contacts/Dentures –NPO status –Changes in medical history URI Hospitalizations Sick family members

Special Considerations Pediatric patients –Not “little adults” Geriatric patients –Unique subclass of patients with physiological changes complicating treatment

“Show Stoppers” Food or fluid intake 6 hours prior to surgery Clear fluid intake within 2 hours of surgery –Can read newspaper print when looking through liquid Recent alcohol ingestion Recreational drug use Pregnancy Thyroid Dysfunction

“Show Stoppers” Recent asthma attack or respiratory failure Treatment with MAO inhibitors Tricyclic Antidepressants Adrenal Dysfunction Renal Dysfunction

Technician Responsibilities Pre-Procedure Patient Assessment –Informed Consent –Escort Present –Establishes patient’s mental status Under the influence of alcohol or drugs Oriented to person, place, time –Document on AF 1417 Clinical Sedation record

Technician Responsibilities Pre-Procedure Patient Assessment –Supplemental oxygen applied –Suction functioning

Technician Responsibilities Intraoperative Responsibilities – “Float” –Informed consent signed prior to sedation –Name, dose, route and time of all medications documented –Procedure begin and end times –Prior adverse reactions –Pre-medication time and effect

Technician Responsibilities Intraoperative Responsibilities – “Float” –Vital Signs BP Heart Rate Respiratory Rate Oxygen Saturation Level of Consciousness

Technician Responsibilities Post-operative Responsibilities – “Float” –Vital Signs at least every 5 minutes BP Heart Rate Respiratory Rate Oxygen Saturation Level of Consciousness Sedated patients must be continuously monitored until discharged

The following values are indicative of the “normal” adult patient. Pediatric and Geriatric patients have different values and unique characteristics for which the anesthesiologist/surgeon must be aware

Blood Pressure Specifically mean arterial pressure (MAP) –MAP Systolic BP – Diastolic BP/3 + Diastolic BP Also written as Diastolic BP + 1/3 Pulse Pressure Normal Body loses autoregulatory capacity at a MAP less than 50 or greater than 150

Heart Rate Normal range 60-90

Respiratory Rate Normal range per minute

Oxygen Saturation Must be greater than 90% Supplemental oxygen via nasal cannula is required in the OMFS clinic during sedation –Initially 2-3 liters/minute In the OSOR supplemental oxygen is supplied by nasal cannula or endotracheal tube

Recommended Alarm Limits LowHigh Systolic BP85150 Diastolic BP50100 Rate BPM50110 SP O292100

Level of Consciousness Must be able to respond to verbal stimuli by the surgeon in the clinic May be greatly sedated or unable to arouse by verbal stimuli in the operating room

Technician Responsibilities Post-operative Responsibilities – “Float” –ALDRETE Post-Operative Scoring System A cumulative score of 8 or above is necessary for discontinuation of monitoring –We generally use a goal of 10 as necessary for dismissal from clinic –Sum of standardized measurements of movement, respiration, circulation, color and level of consciousness

Movement Move all 4 extremities2 Move 2 extremities1 No control0

Respiration Breathe deep and cough2 Dyspnea1 No respirations0

Circulation BP +/- 20% pre-sedation level2 BP +/ % pre-sedation level1 BP +/- > 50% pre-sedation level0

Consciousness Fully alert2 Arousable1 No response0

Color Pink2 Pale, Dusky, Blotchy1 Cardboard0

The Key to Sedation Local Anesthesia –If a poor local anesthetic block has been given, the patient will continue to feel pain throughout the procedure

Valium (Diazepam) Benzodiazepine Produces sleepiness and relief of apprehension Onset of action 1-5 minutes Half-life –30 hours –Active metabolites Average sedative dose –10-12 mg

Versed (Midazolam) Short acting benzodiazepine –4 times more potent than Valium Produces sleepiness and relief of apprehension Onset of action 3-5 minutes Half-life – hours Average sedative dose – mg

Demerol (Meperidine) Narcotic Pain attenuation and some sedation Onset of action –3-5 minutes Half-life –30-45 minutes Average dose –20-50 mg

Fentanyl (Sublimaze) Narcotic/Opiod agonist –100 times more potent than Morphine Pain attenuation and some sedation Onset of action around 1 minute Half-life –30-60 minutes Average dose –0.05 – 0.06 mg

Additional Medications Likely to be seen in scenarios where deeper levels of sedation are being performed –Propofol (Diprivan) –Robinul (Glycopyrrolate)

Propofol (Diprivan) Intravenous anesthetic/sedative hypnotic Sedative, anesthetic and some antiemetic properties Onset of action within 30 seconds Half-life –2-4 minutes Average sedative dose –Varies

Robinul (Glycopyrrolate) Anticholinergic –Heart rate increases –Salivary secretions decrease Dose mg Onset of action within 1 minute

Medical Emergency Syncope Hypoglycemia Hypotension Hypertension Bronchospasm Laryngospasm Apnea Myocardial infarction Stroke

Medical Emergency Know when and how to activate a “Code Blue” Location of Crash Cart –Medications –Monitors Location of emergency medications BLS

Medical Emergency Know how to prevent, recognize, and treat syncope (fainting) –Supplemental O2 –Elevation of lower extremities –Trendelenburg Be prepared to assist in airway management

Emergency Drugs These are included for reference only Technicians should not be administering medications to patients without advanced training in ACLS and direct provider supervision

Emergency Drugs Flumazenil (Romazicon) Naloxone (Narcan) Esmolol (Brevibloc) Ephedrine Epinephrine Atropine

Flumazenil (Romazicon) Benzodiazepine antagonist –Versed reversal agent Initial dose – 0.2mg –May repeat at 1 minute intervals to dose of 1mg Onset of action within 1-2 minutes Must monitor for re-sedation –May be repeated at 20 minute intervals as needed

Naloxone (Narcan) Narcotic antagonist –Fentanyl reversal agent Initial dose – 0.4mg –May repeat every 2-3 minutes at doses of mg Monitor for re-sedation

Esmolol (Brevibloc) Antihypertensive Beta blocker Initial dose 0.25 –1.0 mg/kg over 30 seconds –Short half-life of approximately 10 minutes

Ephedrine Used for hypotension Sympathomimetic Initial dose 5-10mg Action may not be seen for several minutes

Atropine Significant bradycardia or asystole –Slow heart beat or NO heartbeat Anticholinergic Initial dose 0.25 – 1.0 mg –May repeat every 3-5 minutes –Maximum total dose.03 mg/kg

Epinephrine True emergency medication Administration should be preceded by activation of the 911 emergency response system

Questions