conscious

sedation

PRESENTED BY:
ROSHNI MAURYA
1ST YEAR PGT
INTRODUCTION
 In the past decade, the use of sedatives and analgesics
to relieve pain and anxiety associated with invasive
diagnostic and therapeutic/painful procedures on
pediatric patients in
non-traditional settings (i.e., Emergency Department,
Radiology, EEG lab, etc.) has substantially increased.

 Further complicating matters, there is very little existing

conformity in providers’ choice of technique,
medication(s)
and depth of sedation/anesthesia to accomplish the
same procedure.

 Consequently, adhering to a systematic approach of

appropriate assessment, monitoring, and rescue skills
has become critically important in promoting safe and
effective procedural sedation and analgesia.
 Purpose:
 To familiarize with principles and
standards
underlying safe and effective pediatric
moderate sedation,
 review optimal presedation patient
evaluation,
 review commonly used
sedative/analgesic
drugs,
 review potential patient complications,
provide resources to improve patient
safety and outcomes.
 Procedural Sedation in
Children
Children receive sedation more frequently than
adults (largely due to diagnostic procedures
that require controlled/no movement).
To meet necessary goals, sedation/analgesia
usually must be deeper than given to
adults.
Due to physiologic differences, children are at
higher risk for respiratory depression and
life-threatening hypoxia.
Technically, providers with the intent to practice
“moderate sedation” may be closer to the
definition of “general anesthesia” because
children can easily slip from one level to
another.
 Procedural
Sedation/Analgesia
Continuum
 Procedural
Sedation/Analgesia Continuum
Some general information regarding the definition and
categorization of procedural sedation.

Sedation/analgesia is defined by a continuum of

“levels” ranging from minimally impaired
consciousness to unconsciousness.

The following terminology refers to the different

levels of sedation intended by the practitioner
Minimum moderate dissociative deep
general anesthesia

Remember: Levels of sedation are considered

to be on a continuum because a sedated child
can go in and out of an intended level quite
rapidly.
Continuum – Minimal
Sedation
Minimal Sedation (Anxiolysis) = a drug-induced state during
which children respond normally to verbal commands.
Although cognitive function and coordination may be
impaired, ventilatory and cardiovascular functions are
unaffected.
Note: This level is rarely adequate for an infant or young child
undergoing
sedation for a procedure.
Continuum – Moderate
Sedation
Moderate Sedation (formerly Conscious Sedation) = a drug-
induced depression of consciousness during which sedatives
or combinations of sedatives and analgesic medications are
often
used and may be titrated to effect.

Children respond purposefully to verbal commands, either

alone or accompanied by light tactile stimulation.
No interventions are required to maintain a patent airway,
and spontaneous ventilation is adequate. Cardiovascular
function is usually maintained.
 Continuum – Dissociative
Sedation
Dissociative Sedation = (Ketamine) A trancelike, cataleptic state occurs
with both profound analgesia and amnesia while maintaining protective
airway reflexes, spontaneous respirations, and cardiopulmonary
stability.

 Child’s eyes remain open with nystagmic gaze; may exhibit random
tonic movements of extremities.

 Causes hyperactive airway reflexes, with a risk of Laryngospasm.

 Does not blunt protective airway reflexes to the same degree as

Deep Sedation
other sedatives (e.g., opioids, benzodiazepines ).Sedation
Minimal

Dissociative

Consciousness

Unconsciousness
Moderate Sedation
General Anesthesia
Continuum – Deep Sedation
Deep Sedation = a drug-induced depression of consciousness
during which patients cannot be easily aroused, but respond
purposefully following repeated or painful stimulation.

 The ability to independently maintain ventilatory function may

be impaired.
 Patients may require assistance in maintaining a patent airway,
and spontaneous ventilation may be inadequate.
 Cardiovascular function is usually maintained.
Continuum – General
Anesthesia
General Anesthesia (GA) = a drug-induced loss of consciousness
during which patients are not arousable, even by painful stimulation.

 The ability to independently maintain ventilatory function is often

impaired.
 Patients often require assistance in maintaining a patent airway,
and positive pressure ventilation may be required because of
depressed spontaneous ventilation or drug-induced depression of
neuromuscular function.
 Cardiovascular function may be impaired.
Preparation
Goals of Effective Sedation
Guard the patient’s safety & welfare

Minimize physical discomfort & pain

Control anxiety, minimize psychological

trauma, and maximize the potential for
amnesia

Control behavior and/or movement to allow the

safe completion of the procedure

Return the patient to a state in which safe

discharge from medical supervision (as
determined by recognized criteria) is possible
 Strike
Strike aa Balance
Balance
 MAXIMIZE benefits while minimizing the associated
risks
Laryngospasm Maximize
Minimize amnesia Minimize
Airway pain & psychological
Hypoventilation Death obstruction discomfort trauma/anxiety
Cardiac
depress Apnea Control
ion movement
BENEFIT
RISK
Before We Begin…
 Each sedation should be tailored to the
individual child considering the following factors:

 Select the lowest drug dose with the highest

therapeutic
index for the procedure - consider if agent(s) can be
reversed

 Consider whether the procedure could be

accomplished
without sedation by engaging alternative modalities

 Alternatively, do not undertreat the child when

sedation/analgesia is appropriate & necessary
 Implications
 No matter the level of sedation you intend to produce,
you should be able to rescue patients one level of
sedation “deeper” than that which was intended.
– Joint Commission

For example: You must be prepared/skilled to manage

and rescue a “moderately sedated” child who slips
into an unintentional state of “deep sedation.”

This highlights the fact that different levels of sedation

require different levels of expertise in airway &
physiological function management of the patient.
 Principles
for
Safe & Effective
Sedation/Analgesia
Foundation for Safe Sedation
 Patient evaluation

Monitoring Rescue
Skills
Guiding Principles – Supervision &
Training
The following action items are necessary to ensure safe
sedation1
Supervision & Training
Children should not receive sedative or anxiolytic
medications without supervision by medical
personnel appropriately trained & skilled in
both airway management and
cardiopulmonary resuscitation.
 Do not prescribe (or encourage) any sedating
medications to be administered by the parent before
arriving at the hospital.

Formulate a reasonable plan of

sedation/analgesia.
Understand the pharmacokinetics/dynamics
and interactions of sedating medications.
Guiding Principles – Staffing
Staffing
Ensure that an adequate number or
trained/credentialed/competent staff are
present for procedure and monitoring
(minimum of two experienced
providers).

Specifically assign a staff member

whose main responsibility it is to
constantly monitor the child’s
cardiorespiratory status during & after
the procedure, and assist in supportive
or resuscitation measures (as required).
Ensure a properly equipped & staffed
recovery area (note: parents/caregivers
should not be considered as part of the
staff).
Guiding Principles – Evaluation
Evaluation

Conduct a focused airway evaluation

(potential complications include:
large tonsils, anatomic airway
abnormalities, loose teeth, etc.).

Conduct a thorough presedation evaluation

for underlying conditions that would increase
the risk ( wheezing etc.). Screen for medications the
child takes at home and/or allergies the child may
have.
Ensure appropriate fasting (balance the risk/benefit
of shortened fasting in emergent situations).
Guiding Principles – Equipment &
Disposition
Equipment
Have access to all appropriate medications and reversal
agents.
Use age/size-appropriate and functioning
equipment for airway management
& venous access.

Disposition
Ensure patient is recovered to baseline
status before discharge. Appropriately
manage pain.
Provide appropriate discharge instructions to
parent/caregiver.
Personnel & Training
Primary Practitioner:

Be qualified and institutionally credentialed to

administer drugs to predictably achieve and
maintain the desired level of sedation
Recognize and manage complications of one
level deeper than intended sedation
Be trained/capable of providing (at minimum)
bag mask ventilation and, ultimately,
endotracheal intubation
Understand pharmacology of sedating
medications, as well as role of reversal agents
for opioids and benzodiazepines
Maintain advanced pediatric airway skills
Support personnel:

At least 1 person dedicated to constantly

monitor appropriate physiologic
parameters and assist in any supportive or
resuscitation measures

Be trained in, and capable of providing,

pediatric basic life support

Know how to use resuscitation

equipment & supplies in the event of an
emergency
THIS PERSON SHOULD HAVE NO OTHER SIGNIFICANT
RESPONSIBILITIES
Sedation/Analgesia
Specifics
 Sedation Considerations
Consider each of these factors when planning for sedation
 Procedural issues:
 What type -- therapeutic (painful) vs. diagnostic (non-painful)?
 What is the child’s health status, age/development level & personality
type?
 How stressful/anxiety-producing is the procedure (e.g., sexual abuse
evaluation)?
 Is immobility/behavior control required?
 What position will the child be in during the procedure?
 How much time will it take to complete the procedure?
 How quickly can rescue resources be available?
 Medication issues:
 What is the mechanism of action?
 How is the sedating/analgesic agent metabolized?
 What is the duration of action? (avoid dose stacking)
 Potential adverse reactions/monitoring issues:
 Need for appropriate reversal agent
 Medication side effects/allergic reactions
 Oxygen desaturation
 Laryngospasm
 Hypotension
 Equipment & Supplies
To ensure systematic & thorough preparation
for every sedation, the AAP1 recommends S O A P M E

 Suction – age/size-appropriate suction catheters and suction

apparatus (Yankauer-type)
 Oxygen – adequate O2 supply, working flow/delivery
devices
 Airway – age/size-appropriate airway equipment (e.g., ET
tubes, LMAs,
oral and nasal airways, laryngoscope blades, stylets, bag
mask)
 Pharmacy – all basic life-saving drugs, including reversal
agents (Naloxone, Flumazenil)
 Monitors – pulse oximeter, BP monitor, ECG, stethoscope,
thermometer, cardiac monitor, end-tidal carbon dioxide
(EtCO2) monitor/detector
 Equipment – special equipment/drugs for particular child
(e.g., defibrillator, respiratory box, IV access equipment)
should be readily available
 MOST IMPORTANT PERSONNEL SKILLED
IN ADVANCED LIFE SUPPORT!
 Presedation Evaluation
 Evaluate every child in need of procedural sedation prior to sedation
& perform universal procedures (i.e., “time out”) immediately prior to
sedation.
Age, weight, height Systems review

Health history Vital signs (BP, heart rate,
respiratory rate, temperature,
Allergies and previous allergic SpO2)
or adverse drug reactions
Pulmonary, Cardiac, Renal,
Medication history, herbal or GI, Hematological, CNS,
illicit drugs (dosage, time, route, Endocrine
and site) Physical exam with focused
airway evaluation (include:
Relevant diseases, physical body habitus, head/ neck,
abnormalities, and pregnancy teeth/mouth, and jaw)
status
Physical status
Relevant hospitalizations Review of objective
Prior sedations & surgeries, diagnostic data (e.g. labs,
and any complications (esp. ECG, x-ray, etc.)
airway issues) Level of child’s anxiety, pain,
consciousness
Relevant family history
NPO status Name and telephone
 Airway Evaluation
MALLAMPATI AIRWAY CLASSIFICATION Mallampati classification
system is a standard airway
View = patient seated with evaluation used as a method
Class mouth open as wide as to predict difficult intubation.
possible Assess ability to open
mouth and protrude
tongue
Soft palate, fauces, uvula,
I
tonsillar pillars Check for loose teeth
II Soft palate, fauces, full uvula
Assume that it may be
III Soft palate only necessary to establish an
artificial airway during any
IV Hard palate only sedation.

Anticipate any/all
obstacles before the real
time occurrence.

Class III & IV = potential

difficult intubation
(consider anesthesia
consult)
ASA Physical Status
Classification
In 1941, the ASA developed a classification for a patient's
physical status before sedation/surgery to alert the medical
team to the patient's overall health.
STATUS DISEASE STATE EXAMPLES

I Healthy, normal child

Child with mild systemic Controlled asthma, controlled

II disease diabetes
Active wheezing, diabetes
Child with severe systemic mellitus w/ complications,
III* disease heart disease that limits
activity
Child with severe systemic
Status asthmaticus, severe
IV* disease that is a constant
BPD, sepsis
threat to life
Child who is moribund and
Cerebral trauma, pulmonary
V* not expected to survive
embolus, septic shock
without the procedure

*Anesthesia consultant is usually required

 ASA/AAP NPO Guidelines
NPO Guidelines for Elective* Sedation

INGESTED TIME

Clear Liquids (water, fruit juices w/o pulp, carbonated

2 hours
beverages, clear tea, black coffee)
Breast milk 4 hours
Infant formula 6 hours
Nonhuman milk (similar to solids) 6 hours
Solids (light meal; if includes fatty/fried food, consider
6 hours
longer faster period)

*In emergency situations, carefully weigh the need for immediacy with the
increased risk of pulmonary aspiration. Use the lightest effective sedation
possible.
 Documentation – Before & During
Before Sedation During Sedation
 Presedation health evaluation (include
initial aldrete score) On a time-based flowsheet:
 Confirm staff privileges & universal
procedures (i.e., “time out”)
 Drug name(s) & drug
 Drug calculations (include reversal calculations
agents and local anesthetics)
 Route
 Informed consent (risks vs. benefits,  Site
alternatives to planned sedation)
 Time
 Instructions to family:  Dosage (titrated to desired
 Objectives of sedation effect)
 Anticipated changes in behavior
(during & after)
 Why/when to expect longer During administration, record:
observation time (drugs with long
half-lifes; severe underlying
condition; neonates/preemies, etc.)
 Special transport instructions for  Inspired concentrations of O2 &
children going home in car seat duration of sedating/analgesic
(child’s head positioning)
 24-hour emergency phone # agents
 Level of consciousness
 Heart rate, respiratory rate, SpO2
Document at least once every 5 minutes until  Adverse events and corrective
intervention/treatment given
child reaches predetermined discharge criteria
Documentation - After
During the recovery & discharge phase,
document the following:

Time and condition of child upon discharge

Level of consciousness

SpO2 on room air

Modified Aldrete Score11 (also known as the

Postanesthesia Recovery Score)

Child meets all predetermined discharge criteria

Monitoring - During
During sedation, continuously monitor:
 SpO2
 Heart rate
 Respiratory rate
 Head position/airway patency
 Blood pressure (forego if interferes with sedation)
 Level of sedation (e.g., Modified Ramsey Scale12)
 ECG monitoring (esp. child with significant CV disease
or dysrhythmias)

 Ensure all monitors & alarms are working &

routinely safety-checked
Monitoring - Transport
If the child is transported while sedated,
don’t forget to:
 Have credentialed/competent/skilled personnel
accompany
 Monitor all vital signs
 Monitor level of consciousness
 Monitor SpO2
 Bring necessary O2 supplies (tank, tubing, face mask,
bag mask, oral airway, etc.)
 Bring necessary emergency drugs (including reversal
agents)
 Bring cardiac monitor (esp. child with significant CV
disease or dysarrhythmias)
 Monitoring - After
During recovery:

 Continuously observe and monitor ,heart rate,and level

of consciousness until the child is fully alert
 Monitor other required vital signs at specific intervals until
the child meets appropriate discharge criteria
 Ensure adequate pain management as effects of
sedation/analgesia begin to wear off
 Observe for longer periods of time if child:
Received any reversal agents (duration of sedating
agents may exceed duration of antagonist)
Received sedating agents with a long half-life (e.g.,
chloral hydrate) that may delay return to baseline or pose
risk of resedation
Discharge Criteria
Every hospital must develop discharge criteria based on
objective measures suitable to their patient population.

Consider, at minimum, the following measures:

 Return to pre-sedation (age/developmentally-appropriate)
activity/ambulation & cognitive level
 Child is easily arousable, alert and oriented
 Protective airway reflexes are intact
 Stable vital signs, pain level, O2 and respiratory effort (e.g. Modified Aldrete
Score ≥ 9)
 If reversal agent is given, allow sufficient time (up to 2 hours) after last
dose to observe for risk of resedation
 Child/caregiver is able to understand written instructions (include
emergency contact #)
 Child has safe transportation home with responsible adult (for infants
going home in a car seat, adjust head position to ensure a patent airway if
infant falls asleep)
 PRE ANESTHETIC
MEDICATION

Refers to the use of drugs before

anesthesia to make it more pleasant &
safe.
 AIMS & OBJECTIVES
 Relief of anxiety , apprehension preoperatively , to
facilitate smooth induction
 Amnesia for pre & postoperative events.
 Supplement analgesic action of anesthetics.
 Decrease secretions, vagal stimulation caused by
anesthetics
 Anti –emetic effect extending to postoperative
period.
 Decrease acidity , volume of gastric juice so less
damaging if aspirated.
DRUG DOSAGE ROUTES OF FEATURES
ADMINISTRA
TION
opioids morphine (10 mg) im allay anxiety, apprehension
pethidine( 50-100 of procedure , produce pre
mg) & post operative analgesia,
smoothen induction, reduce
dose of anesthetic agent

sedative diazepam (5-10mg) oral produce tranquility, smooth

anti lorazepam (2mg) im induction
anxiety
drugs
anti atropine(0.6mg) im to reduce sal.& bronchial
cholinergic iv secretions
s

neuroleptic chlorpromazine(25 im allay anxiety , smoothen

s mg) induction , have antiemetic
effect

h2 ranitidine (150mg) oral reduces ph of gastric juices

blockers may reduce its volume

anti metaclopramide(10- im reduces post operative

emetics 20 mg) vomiting
SEDATION TECHNIQUES
 Inhalation sedation
 Oral sedation
 Intramuscular sedation
 Submucosal sedation
 Intravenous sedation
 Rectal sedation
NITROUS OXIDE SEDATION

 Nitrous oxide/oxygen inhalation

sedation is the most commonly
used technique in dentistry.
 Equipment

Continuous flow design with flow meters

Safe delivery of O2 and N2O (fail safe
mechanism)

Pin-indexed yoke system

Efficient scavenger
 Nasal Mask

Selection of an appropriately sized nasal hood should be made. A

flow rate of 5 to 6 L/min generally is acceptable to most
patients(AAPD,2009)
 Thorough inspection of equipment

Place the mask over nose

Bag is filled with 100% oxygen and delivered to patient for 2 –

3 mins
Slowly introduce nitrous oxide

Encourage the patient to breathe through

nose
Explain the sensation to be felt- floating, giddy, tingling of
digits

Adjust the concentration to 30% nitrous oxide and 70%

oxygen

Carry out the procedure with continuous monitoring

After completion of procedure give 100% oxygen for 5

Advantages
 Ability to titrate & to reverse
 Rapid onset & recovery
 Patient can be discharged alone
Disadvantages
 Patient acceptance is not universal
 Cost of the equipment
 Not always effective
C/I
 Nasopharyngeal obstruction
 COPD
 Pregnancy
Potential Problems

 Diffusion hypoxia
 Vomiting
 Toxicity inhibit vitamin B12 dependent
enzymes (Pernicious anemia)
 Reproductive Abnormalities
Commonly Used Agents
DRUG ROUTE DOSAGE ADVANTAGES DIS – PROPERTIE
ADVANTAGES S
Hydroxyzi Oral 0.6 mg/kg Rapidly Dry mouth, •Clinical
ne IM 1.1 mg/kg absorbed from drowsiness, effect seen in
GIT hypersensitivity 15-30 min
•Half life of 3
hours
Promethaz Oral 0.5 mg/kg Sedative and Dry mouth, •Onset – 15
ne IM 1.1 mg/kg antihistaminic Blurred to 16 mins
properties,well vision,thickenin •Metabolized
absorbed after g of bronchial in liver
oral ingestion secretions,hypo •Potentiates
-tension CNS
depressant
Diphenhy Oral 1.0 – 1.5 Absorbed GIT, Disturbed •Maximum
– IM, IV mg/kg eliminated in 24 coordination, effect in 1
dramine hours epigastric hour
distress •Metabolized
in liver
•Mild sedative
Diazepam Oral 0.2-0.5 mg/kg Sedative and Ataxia,respirato •Lipid soluble
Rectal 0.25 mg/kg Anxiolytic, ry depression in and water
IV rapidly high doses, hours
Midazol Oral IM 0.25-1mg/kg High water Apnea, •Packed at 3.3
am 1-0.15mg/kg solubility, prolonged PH, changes
sedation in 3-5 CNS effects, to 7.4 on
min and rebound entering
recovery in 2 effect blood.
hrs ,no •Highest lipid
rebound effect solubility
,rapid •Very less half
absorption from life
GIT
Chloral Oral, 25 – 50 Commonly used Irritating to •Onset: 15-30
hydrate Rectal mg/kg fro children due gastric mins
to its well known mucosa, •Half life is 8-10
effects drowsiness hrs
Fentanyl IM, IV 0.002-0.004 Potent Respiratory •Metabolized in
Mg/kg analgesic,rapid depression liver
onset •Excreted in
urine
•Onset: 7-15
min
Ketamin IM,IV 1.5 mg/kg Potent analgesic, Gastric Safety not yet
e rapid onset: 1 distress established
min in IV and 5 ,apnea , CVS •Fast onset and
min I IM disorders, short duration
CONCLUSION
Dental Chair Anesthesia is steadily gaining
popularity
challenging, new, unexplored but promising
territory
Balancing of ‘Pros & Cons’ for: conscious
sedation,
relative analgesia or GA
Setting up the services is as such not easy,
cheap,
or frivolous and simple
Must be done by trained qualified
anesthesiologists
THANK U!