1. Conscious Sedation Dr. Rahaf Al-Habbab BDS. MsD. DABOMS
Diplomat of the American Boards of Oral and Maxillofacial Surgery

2. Why Do Most People Avoid Going To The Dentist?
FEAR

3. Office Anesthesia To facilitate surgery and patient comfort Amnesia
Analgesia
Conscious Sedation
Ambulatory General Anesthesia (No Intubation)
Hypnosis
Immobilization

4. 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

6. How will you assess this patient?
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?

7. Pre-Operative Evaluation
PMH
Medication, Allergies
ASA Classification
Vital Signs: BP, Pulse, RR, Oxygen Saturation, Height, Weight
Physical Exam
Airway Exam

8. Pre-Operative Evaluation
PMH
Medication, Allergies
ASA Classification
Vital Signs: BP, Pulse, RR, Oxygen Saturation, Height, Weight
Physical Exam
Airway Exam

9. ASA Classification
General Pre-Anesthetic Evaluation American Society of
Anesthesiologists (ASA) Physical Status Classes
ASA I A normal healthy patient
ASA II 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

10. Pre-Operative Evaluation
PMH
Medication, Allergies
ASA Classification
Vital Signs: BP, Pulse, RR, Oxygen Saturation, Height, Weight
Physical Exam
Airway Exam

12. Pre-Operative Evaluation
PMH
Medication, Allergies
ASA Classification
Vital Signs: BP, Pulse, RR, Oxygen Saturation, Height, Weight
Physical Exam
Airway Exam

13. Mallampati Classification
Airway
Mallampati Classification

14. Airway
Class I
Facial pillars, soft palate, and uvula are visible

15. Airway
Class II
Facial pillars, soft palate, and part of the uvula

16. Airway
Class III
Soft Palate, and Base of Uvula

17. Airway Class IV Only soft palate is visible
Intubation is predicted to be difficult

18. Airway Airway Evaluation
Thyromental distance not less than 3-4 finger width

19. Airway Predictors of a difficult Airway: Obesity Mouth opening
Thyromental distance
Mental-hyoid distance
Retrognathia

20. Pre-operative Instructions
Why “NPO” Guidelines?
To avoid aspiration pneumonia
To prevent foreign body obstruction

21. NPO Guidelines Guidelines for pre-operative fasting
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

22. Equipments

23. IV Puncture Butterfly Needles: Short metal needle Easy to place
Winged tabs permit easy securing point
Short needle reduces patient anxiety

24. IV Puncture Angiocatheter Indwelling peripheral catheter
Catheter over needle
Needle serve as an introducer
Variable length and gauges of needles

25. IV Fluids IV Fluids provide hydration
Administration of anesthetic agents and emergency medication

26. IV Fluids
Choose what you need and need what you choose

27. 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)

28. Monitoring

29. BP HR
Pulse Oximetry RR
3 Lead ECG
End Tidal CO2

30. 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.

31. Monitoring
Respiratory Monitoring
1- Oxygen Monitoring
Pulse Oximetry

32. Monitoring Visual inspection (see the chest rise)
2- Ventilatory Monitoring:
Visual inspection
(see the chest rise)
Pretracheal Stethoscope
(precordial)
End-tidal CO2

33. Second Part

34. Drugs

35. Drugs No drug ever exerts a single action
No clinically useful drug is entirely devoid of toxicity

36. Drugs Ideal anesthetic agents for ambulatory general anesthesia:
Rapid onset
Short duration of clinical effect
High clearance rate
Minimal tendency for drug accumulation

37. Benzodiazepines 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
Diazepam (VALIUM)
Midazolam (VERSED)
Reversal: Flumazenil

39. 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)

40. 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

42. Anesthetic Agents Ketamine
A dissociative anesthetic
Pharmacological immobilization “chemical straight-jacket”
Used as an adjunct to general anesthesia

43. Guedel’s Classification
Stage of Analgesia
Stage of Delirium
Stage of Surgical Anesthesia
Respiratory Paralysis

44. Guedel’s Classification
Stage of Analgesia
Stage of Delirium
Stage of Surgical Anesthesia
Respiratory Paralysis

45. 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

46. Guedel’s Classification
Stage of Analgesia
Stage of Delirium
Stage of Surgical Anesthesia
Respiratory Paralysis

47. Guedel’s Classification
Stage II: Delirium
CNS Depression is more pronounced
Patient may briefly lose consciousness
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
Patients will likely be hyper-responsive and difficult to manage
During induction, stage II is typically bypassed
CONFUSION

48. Guedel’s Classification
Stage of Analgesia
Stage of Delirium
Stage of Surgical Anesthesia
Respiratory Paralysis

49. Guedel’s Classification
Stage III: Surgical Anesthesia
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

50. 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

51. Guedel’s Classification
Stage of Analgesia
Stage of Delirium
Stage of Surgical Anesthesia
Respiratory Paralysis

52. 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)

53. Conscious Sedation The patient maintain all reflexes
The patient can respond to verbal command
Drugs are titrated to effect

54. Ambulatory General Anesthesia
Diazepam or Midazolam
Fentanyl
Propofol
+/- Kitamine

55. Pediatric Cases
Nitrous Oxide Or
Oral Midazolam
IM Ketamine

56. The End