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
