ANESTESI UMUM DAN LOKAL

drg. Puspito Ratih H., MDSc., Sp.Perio

 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
 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
 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
 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 80-100
 Body loses autoregulatory capacity at a MAP less
than 50 or greater than 150
 Heart Rate

 Normal range 60-90

 Respiratory Rate

 Normal range 10-16 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

Low High
Systolic BP 85 150
Diastolic BP 50 100
Rate BPM 50 110
SP O2 92 100
 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 extremities 2

 Move 2 extremities 1
 No control 0
 Respiration

 Breathe deep and cough 2

 Dyspnea 1
 No respirations 0
 Circulation

 BP +/- 20% pre-sedation level 2

 BP +/- 21-50% pre-sedation level 1
 BP +/- > 50% pre-sedation level 0
 Consciousness

 Fully alert 2
 Arousable 1
 No response 0
 Color

 Pink 2
 Pale, Dusky, Blotchy 1
 Cardboard 0
 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
(anxiety/fear)
 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
 1.2-12.3 hours
 Average sedative dose
 2.5-7.5 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 0.1-0.2 mg
 Onset of action within 1 minute
 Medical Emergency

 Syncope  Laryngospasm
 Hypoglycemia  Apnea
 Hypotension  Myocardial infarction
 Hypertension  Stroke
 Bronchospasm
 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
 Naloxone (Narcan)

 Narcotic antagonist
 Fentanyl reversal agent
 Initial dose – 0.4mg
 May repeat every 2-3 minutes at doses of 0.4-2mg
 Monitor for re-sedation
 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
 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
 Local anesthesia

 means of pain control

 Local anesthesia has been defined as a loss of
sensation in a circumscribed area of the body caused
by a depression of excitation in nerve endings or an
inhibition of the conduction process in peripheral
nerves
 distinction between local anesthesia and general
anesthesia is that the former produces a loss of
sensation in the nerves without inducing a loss of
consciousness
DESIRABLE PROPERTIES OF A LOCAL
ANESTHETIC

 The local anesthetic should not be irritating

to the tissue when applied.
 The anesthetic action of the agent should be
completely reversible. The time of onset of
anesthesia should be as short as possible.
 Anesthesia produced should last long enough
to allow the dentist to complete the
procedure, not so long that the patient takes
hours to recover from its effect after the
procedure is completed.
 All local anesthetic drugs are eventually absorbed
from the sight of administration into the
cardiovascular system, systemic toxicity of the drugs
is a significant factor to consider in its selection for
use as a local anesthetic.
 The anesthetic drug must be effective regardless of
whether it is injected into the tissue or applied
locally to mucous membranes.
 The drug should be sufficiently potent to give
complete anesthesia in clinically acceptable
concentrations.
 There should be no allergic reaction to the drug.
 It should be stable in solution and readily undergo
biotransformation in the body.
 It should either be sterile or be capable of being
sterilized by heat without deterioration.
ester amida

Butacaine articaine

cocaine bupivacaine

hexycaine Dibucaine

piperocaine etidocaine

tetracaine lidocaine

chloroprocaine mepivicaine

procaine prilocaine

propoxycaine quinoline
Selection of a local anesthetic should
take into account three factors:

 duration of the procedure or the length of time for

which pain control is desired;
 potential for pain after treatment; long duration
agents should be employed when postoperative pain
is thought to be a factor;
 contraindications for a particular anesthetic.
 LIDOCAIN

 Lidocaine is an amide local anesthetic. Compared to

procaine, it possesses more rapid onset of action,
produces more profound anesthesia, and has a
longer duration of action and a greater potency.
Lidocaine is the most widely used local anesthetic in
dentistry.
 Lidocaine is available in three formulations 
2% without a vasoconstrictor, 2% with 1:50,000
epinephrine, and 2% with 1:100,000 epinephrine.
Lidocaine without a vasoconstrictor is rarely used in a
typical dental practice  vasodilating effect limits
pupal anesthesia to about 5-10 minutes leads to high
blood level of the drug  lead to overdose reaction
and the possibility of excessive bleeding into the
region of anesthetic administration.
 2% Lidocaine with 1:50,000 epinephrine resolves
these problems. It produces approximately 60
minutes of pupal and 3-5 hours of soft tissue
anesthesia.
 Lidocaine produces topical anesthetic action in
clinically acceptable concentrations.
 For duration and depth of pain control in a typical
dental patient, 2% Lidocaine with 1:100,000
epinephrine is recommended over 2% Lidocaine with
1:50,000 epinephrine. The lesser amount of
epinephrine in the former solution makes it more
acceptable to those individuals who are sensitive to
vasoconstrictors. 2% Lidocaine with 1:100,000
epinephrine provides excellent hemostatic action by
decreasing tissue perfusion in the region of injection.
 Mepivacaine

 Mepivacaine, an amide category of anesthetic agent,

produces only slight vasodilation. The duration of
pupal anesthesia with mepivacaine without a
vasoconstrictor is 20 to 40 minutes and 2 to 3 hours
of soft tissue anesthesia.
 Mepivacaine is available in 2 formulations: 3%
without a vasoconstrictor, and 2% with a
vasoconstrictor.
 3% Mepivacaine without a vasoconstrictor is
recommended for patients in whom a
vasoconstrictor is not indicated and for dental
procedures not requiring lengthy pulpal anesthesia.
 Mepivacaine without a vasoconstrictor is the most
often administered local anesthetic in pediatric
dentistry and is just as often used in geriatric
patients.
 2% Mepivacaine with a vasoconstrictor gives pulpal
anesthesia of approximately 60 minutes and soft
tissue anesthesia of 3 to 5 hours, similar to those
obtained with Lidocaine-epinephrine solutions.
 Mepivacaine does not produce topical anesthetic
action in clinically acceptable concentrations.
 Prilocaine

 Prilocaine, an amide category of agent, is

characterized by the clinical action delivered
depending upon the type of anesthetic technique
employed.
 There is a significant variation in the duration of
anesthesia produced depending upon whether the
agent is delivered supraperiosteal or nerve block.
 Prilocaine plain through infiltration (supraperiosteal)
produces shorter duration of pulpal (5 to 10 minutes)
and soft tissue (l 1/2 to 2 hours) anesthesia;

 Regional block (e.g., inferior alveolar nerve) provides

pulpal anesthesia for up to 60 minutes and soft
tissue anesthesia for 2 to 4 hours.

 Prilocaine plain is frequently able to provide

anesthesia that is equal in duration to that noted
with lidocaine and mepivacaine with vasoconstrictor.
 Prilocaine is used with vasoconstrictor epinephrine
in the formulation of 1:200,000 which provides
lengthy pulpal anesthesia of 60 to 90 minutes and
soft tissue anesthesia of 3 to 8 hours.
 This formulation has the advantage that it offers the
least concentrated epinephrine solution currently
available.
 Bupivacaine

 Bupivacaine, an amide category anesthetic agent, is

used as a 0.5% solution with 1:200,000 epinephrine.

 It is generally used under circumstances with

lengthy dental procedures requiring pulpal
anesthesia in excess of 90 minutes. (e.g., full mouth
reconstruction and extensive periodontal
operations), and procedures in which postoperative
discomfort is anticipated (e.g., endodontic,
periodontal, and oral surgery).
 One consideration in the selection of Bupivacaine as
an anesthetic agent is the possibility of post
operative soft tissue injury produced by self-
mutilation because of the long lasting anesthesia
produced.
 Etidocaine

 Etidocaine is a relatively new amide anesthetic with

clinical indications identical to those of bupivacaine

 The primary difference in clinical activity between

the two is that etidocaine has an onset of anesthetic
action of about 3 minutes whereas bupivacaine has
an onset of 6 to 10 minutes.
 Nitrous Oxide Sedation

 Nitrous oxide is the most widely used analgesic

agent in dentistry to alleviate patient anxiety and
diminish dental pain.
 There is a direct correlation between the patient
feeling of anxiety and experience of pain.

 In one study, 78% of dental patients reported

experiencing pain and 67% reported expecting pain.
 Therefore, any sedation that reduces patient anxiety
has a good chance of reducing the pain experienced
by the patient.
 In the technique of inhalation sedation, gaseous
agents are absorbed from the lungs into the
cardiovascular system.
 There are many inhalation anesthetics that may be
administered by this route for the production of
sedation, but only one, nitrous oxide, offers a
superior approach to patient management for dental
treatment.
 Inhalation sedation with nitrous oxide (N20) and
oxygen (O2) has significant advantages over other
techniques of sedation and has virtually no
disadvantages.
 It is for this reason that the number of health
professionals using nitrous oxide and oxygen has
risen steadily during the last few years.
 At the concentrations N20 is used in dentistry, it is both an
analgesic (an agent that diminishes or eliminates pain in
the conscious patient) and a sedative (an agent that calms
a nervous or apprehensive patient without loss of
consciousness).
 Nitrous oxide does not block all pain perception and must
be used in combination with local anesthesia for most
dental procedures.
 It is most effective in blocking pain perception in the soft
tissues and may be sufficient by itself to eliminate mild to
moderate discomfort during periodontal instrumentation.
In fact, this may be one of the most beneficial uses of
nitrous oxide with oxygen sedation.
 Nitrous oxide-oxygen psychosedation is used in dentistry
for a variety of purposes:
 to aid in radiographic surveys, prophylaxes, and
impression taking; to effectively reduce gagging; and to
provide a more cooperative patient. Suture removal,
changing dressings and packs, wire and splint removal,
and cementation of crowns may be carried out more
comfortably for the patient sedated with nitrous oxide-
oxygen.
 Operative dentistry, crown and bridge, and nonsurgical
periodontics can be performed with the aid of nitrous
oxide-oxygen, though it is important to use local
analgesia when the operation is anticipated to be a
painful one.
 Oral &
maxillofacial endodontics
surgery

Restorative
periodontics
dentistry

Prosthodontics
 Nitrous oxide-oxygen sedation is sometimes used
during orthodontics and pediatric dentistry, keeping
in mind the limitation that inhalation sedation, to be
effective, requires a cooperative patient willing to
don the nasal hood and to breathe through his nose.
TERIMA KASIH