CONSCIOUS

SEDATION

DEFINITION:
A minimally depressed level
of consciousness that retains
the patients ability to maintain
airway independently and
respond appropriately to
physical stimulation and verbal
command.

Moderate Sedation: A depressed level of

consciousness that carries the risk of losing
protective reflexes.
Sedation Criteria Includes:

ability to retain protective airway reflexes

ability to independently and continuously
maintain a patent airway

ability to respond appropriately to both

physical and verbal stimuli

OBJECTIVES
The patients mood should be altered.
Patient should be conscious, respond to
verbal stimuli.
Patient should be co-operative.
All protective reflexes should be intact.
Vital signs stable and normal.
Childs pain threshold should be
increased.
Amnesia should occur.

INDICATIONS:
Patients
who
cannot
cooperate
or
understand for definitive treatment.
Patient lacking cooperation because of
lack
of
psychological
or
emotional
maturity.
Patients with dental care requirements
but are fear full and anxious.
If long procedures are advocated for a
nervous and apprehensive child.

Routes of Administration
INHALATIONAL (N2O)
ENTERAL ( ORAL OR RECTAL)
PARENTERAL
-Intramuscular

- Subcutaneous
- Intranasal
- Submucosal
- Intravenous

American Society of
Anesthesiology / ASA
Classification
A.S.A. Class 1: No organic, physiologic, biochemical, or psychiatric
disturbance.
The pathologic process for which the operation is to be performed is
localized and does not entail a systemic disturbance.
A.S.A. Class 2: Mild to moderate systemic disease disturbance cause
either by the condition to be treated surgically or by other pathologic
processes:
well-controlled hypertension; and no postural hypertension
history of asthma, no wheezing on day of procedure
anemia; Hct greater or equal to 30 gm
cigarette use; without COPD problems
well-controlled diabetes mellitus;
mild obesity; 20% above ideal body weight (IBW)
age <1 year or >70 years; and pregnancy.

ASA Level Cont.

A.S.A Class 3: Severe systemic disturbance of disease from whatever cause,
even though it may not be possible to define the degree of disability with
finality:
angina;
status post-myocardial infarction; less than 3 months ago
poorly controlled hypertension;
symptomatic respiratory disease (e.g., asthma, COPD); and
massive obesity, greater than 50 pounds or 30% of IBW)
A.S.A. Class 4: Indicative of the patient with severe systemic disorders that are
already life threatening, not always correctable by operation:
unstable angina, unrelieved by Nitroglycerin and rest
congestive heart failure;
debilitating respiratory disease; and
hepatorenal failure.

Mallampati System
The Mallampati system anticipates the
degree of difficulty of endotracheal
intubation from I to IV, by relating
tongue size to pharyngeal size. Patient is
examined in the sitting position, with head
in neutral position and mouth open 5060mm (2-21/2 inches) and the tongue
protruding to the maximum.

Mallampati System Cont.

Characteristics of Potential
Difficult Airway
The following physical characteristics may indicate the
potential for difficult airway management:
Hyponathic jaw (recessed)
Hypernathic jaw (protruding)
Deviated trachea
Large tongue
Short thick neck
Protruding teeth
High arched palate

Patient Classification Scheme

Class I A normal, healthy patient with a localized
pathological process.
Class II A patient with well-controlled systemic
disease which does not limit activity.
Class III A patient with moderate-severe systemic
disease that limits daily activity.
Class IV A patient with severe disease that is a daily
threat to life.
Class V A patient at substantial risk of death within 24
hours.
E Emergency status; added to patient class if
individual is undergoing an emergency procedure.

Equipment Needs
Emergency equipment, including a defibrillator, must be
immediately accessible to every location where
conscious sedation is administered. The equipment
should include, but not be limited to the following:
emergency, resuscitation, and antagonist drugs;
airway and ventilator adjunct equipment for adult and
pediatric patients;
defibrillator;
source for administration of 100% oxygen and
capability for suctioning of the patient.

Oral Route

ADVANTAGES:
Convenience
Economy
Lack of toxicity.
Often Painless

Intra muscularRoute
Advantages:
Faster absorption
Technical Advantages:It requires no special equipment
little or no patient cooperation is
required
full calculated dose can be given with
a high degree of certainty.

Disadvantages:

Onset: Absorption of the injected

drug can be decreased or delayed by
several factors

.
A patient who is cold or very anxious
may
experience
peripheral
vaso
constriction in the area of the injection
significantly decrease the rate of
absorption.
Biggest variable in onset is related to
where the drug is actually deposited.

Subcutaneou
s
Route
ADVANTAGES: Site:- More comfortable
and convenient for the
dentist
as well as the
patient

Disadvantages:
The rate of absorption is slower because
of lesser blood supply.
Tissue Slough: Because the drug is
deposited close to the surface of the
skin or mucosa, tissue sloughing is
possible.
Liability Costs:

Intravenous
ADVANTAGES:Route:
Titration: - Small increments of doses
may be given over a short period of time
until the desired effect is achieved
Test Dose:
Intravenous Access:

DISADVANTAGES:Intravenous Access is
difficult
Placement & maintenance of
I.V. Catheter is difficult.
Require both training &
Extensive Practice.

Agents in
Conscious
Sedation
Sedative-hypnotics.
Anti-anxiety agents.
Narcotic analgesics

SEDATIVE & HYPNOTICS

Name Mode of Effect Side

of drug action
effects
Chlorhy Inhibiting Introduce Gastric
sedation
the
-drate
irritabil
Decrease
reticular
anxiety
ity
activating
System

Increase
pain
threshold

Anti-anxiety Drugs
Drug
Diazepam

Midazolam

Mode of
action

Effect

Decrease
the activity
of limbic
system

Decrease or
remove anxiety
in patients with
mental
retardation

Decrease
the activity
of limbic
system

Anxiolytic &
causes amnesia

Narcotic Analgesics

Drug

Mode of Effect
action

Side
effect

Morphine Increase Cause Resp.

pain
analgesi Distre
threshold
a
ss

General Anesthetics drugs used

in Conscious Sedation
KETAMINE:- Causes:Dissoctative anesthesia
where a cataleptic state
can be induced.
Potent analgesic
Potential for oral use

CONTRAINDICATI
ONS:

Chronic
obstructive
pulmonary
disorder, pregnancy, myasthenia,
epilepsy, obesity, bleeding disorders.
Uncooperative patients, unwilling,
unaccompanied.
Dental difficulties prolonged surgery,
inadequate personnel.