APC 103

IV Sedation

Antianxiety drugs administered IV throughout a procedure at a slower pace, providing a deeper stage I analgesia

• Patient assessment  
  • A health history is taken, a physical examination performed, and signed consent obtained.
  • Baseline vital signs are taken and recorded.
  • Oximetry and electrocardiography are performed and recorded.
  • The patient’s weight is taken and recorded for the determination of dosage. 
• Patient monitoring
• Physiologic measurements are recorded every 15 minutes:
  • Level of consciousness
  • Respiratory function
  • Oximetry
  • Blood pressure
  • Heart rate
  • Cardiac rhythm  

Conscious IV sedation is frequently used by an oral surgeon during such procedures as the extraction of third molars, especially in difficult cases, such as when teeth are impacted and surgical removal of bone is necessary.

Local anesthesia is administered once the patient is stable with IV conscious sedation. This also helps ease postoperative pain until oral analgesics can be taken. 

All medications administered IV are calculated according to the patient’s weight and are additionally titrated according to the vitals and feedback from the patient during the procedure.

What is oximetry? 

A change in a patient’s blood oxygen percentage throughout surgery may indicate that one of the medications (e.g., a narcotic analgesic) administered IV is suppressing the respiratory drive.

In addition to the operating dentist and the assistant, a registered nurse is usually present to properly administer the medications through the IV line and monitor the patient’s vital signs throughout surgery. 

Although vital signs may only be formally recorded every 15 minutes, some dental offices choose to record them more frequently. 

General Anesthesia

A controlled state of unconsciousness with a loss of protective reflexes—including the ability to maintain an airway independently and to respond appropriately to physical stimulation or verbal command—that produces stage III general anesthesia. 

• Pharmacologic makeup
  • Combination of gases
  • N_²O/O_²
  • Halothane or enflurane mixture
  • IV agents such as thiopental sodium and methohexital sodium 

General anesthesia is indicated for severely medically compromised or mentally disabled individuals cannot be adequately treated in a regular dental setting.

Because of the loss of protective reflexes with general anesthesia, the patient is intubated, usually through the nose (to keep the oral cavity clear), for delivery of oxygen and anesthetic gases; other medications are administered simultaneously by way of an IV line.

A thorough preoperative examination, including a physical examination, blood tests, and sometimes cardiac tests, is performed and reviewed as part of the medical history before the administration of general anesthesia. 

Both inhalation gases and IV agents are calculated and chosen according to the patient’s health history, the anticipated length and type of surgery, and the anesthesiologist’s preferences.

Four Stages of General Anesthesia

• Stage I: analgesia 
  • At this stage the patient is relaxed and fully conscious. 
  • The patient is able to keep his or her mouth open without assistance and is capable of following directions. 
  • The patient has a sense of euphoria and a reduction in pain. 
  • Vital signs are normal. 
  • The patient can move into different levels of analgesia. 
• Stage II: excitement 
  • At this stage the patient is less aware of his or her immediate surroundings. 
  • The patient starts to become unconscious. 
  • The patient may become excited and unmanageable.
  • Nausea and vomiting may occur.
  • This is an undesirable stage. 
• Stage III: general anesthesia 
  • This stage of anesthesia begins when
    the patient becomes calm after stage II. 
  • The patient feels no pain or sensation.
  • The patient will become unconscious.
  • This stage of anesthesia can be met only under the guidance of an anesthesiologist in a controlled environment such as a hospital.
• Stage IV: respiratory failure or cardiac arrest 
  • At this stage the lungs and heart slow down or stop functioning.
  • If this stage is not reversed quickly, the patient will die. 

What is an example of a stage I anesthesthetic agent? (Nitrous oxide/oxygen.)

Monitoring of the level of consciousness is important to ensure that the titration of the anesthetic is desirable.

Patients undergoing IV conscious sedation should have their vital signs monitored carefully as they are put into a deeper stage I level of anesthesia.

Although the patient is thought to feel no pain, local anesthesia is usually administered to control bleeding throughout the procedure, as well as at or near the end to help with postoperative pain control.

A throat pack is always placed so that the airway and esophagus are protected from instruments, irrigating solutions and blood, materials, and free tissue debris, as well as to keep the stomach from filling with liquid that may cause postoperative nausea and vomiting.  

Because of the risk, it is very important that patients be well-informed, that they thorough discuss the dental office’s consent form, and that all other anesthetic options have been exhausted or found to be inappropriate before general anesthesia is chosen.

General Anesthesia

• Patient preparation
  • Preoperative physical examination
  • Laboratory tests
  • Signature of patient or legal guardian on a consent form
• Preoperative instructions
  • The dentist will review the procedure, as well
    as the risks.
  • The patient must not have anything to drink or eat 8 to 12 hours before undergoing general anesthesia.

“NPO” stands for a Latin abbreviation meaning “nothing by mouth.”

Depending on the serious mess of the dental surgery and the outcome, most patients will be treated as day surgery patients; others will have to remain in the hospital, monitored in a controlled environment for a prescribed amount of time after surgery.

Recordkeeping for Sedation Methods

• Always document the following measures
  and observations:
  • Review of the patient’s medical history 
  • Preoperative and postoperative vital signs 
  • Patient’s tidal volume if inhalation sedation is being used 
  • Times at which anesthesia began and ended 
  • Peak concentration administered 
  • Postoperative time (in minutes) required for patient recovery 
  • Adverse events and patient complaints  

Along with a detailed account of the actual surgical procedure, the name, concentration, and amount of anesthesia used; the time at which it was administered; and the route of administration (e.g., local infiltration, IV, inhalation, etc.) should be noted.

For local anesthesia, remember to note whether it contained a vasoconstrictor and. if so, the type and concentration.

Any postoperative instructions should also be documented.