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Intravenous Sedation Monitoring. 59 AMDG/Dental Squadron Technician Orientation Module. Training Objectives. Verification of current BLS training Use of automated monitoring equipment Physiologic norms and overview of medications Overview of medical emergencies

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intravenous sedation monitoring

Intravenous Sedation Monitoring

59 AMDG/Dental Squadron

Technician Orientation Module

training objectives
Training Objectives
  • Verification of current BLS training
  • Use of automated monitoring equipment
  • Physiologic norms and overview of medications
  • Overview of medical emergencies
  • “Code Blue” procedures and “Crash Cart” familiarization
levels of anesthesia
Levels of Anesthesia
  • Local anesthesia
  • Conscious Sedation
  • Deep Sedation
  • General Anesthesia
local 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
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
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
General Anesthesia
  • The elimination of all sensation accompanied by the loss of consciousness
stages of general anesthesia
Stages of General Anesthesia
  • Stage I
    • Analgesia
  • Stage II
    • Delirium
  • Stage III
    • Surgical anesthesia
      • 4 planes of surgical anesthesia
stages of general anesthesia9
Stages of General Anesthesia
  • Stage IV
    • Medullary paralysis
level of anesthesia
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
provider training
Provider Training
  • Must be able to safely manage 1 level of anesthesia beyond plane to be achieved
    • If practicing Deep Sedation you must be able to manage general anesthesia
technician responsibilities
Technician Responsibilities
  • Pre-Procedure
    • Equipment
      • Instruments
      • Venipuncture
      • Monitors
      • Emergency Supplies
        • “Crash Cart”
        • Cardiac Monitor
    • Medications
technician responsibilities13
Technician Responsibilities
  • Pre-Procedure Patient Assessment
    • Vital Signs
    • Allergies
    • Contacts/Dentures
    • NPO status
    • Changes in medical history
      • URI
      • Hospitalizations
      • Sick family members
special considerations
Special Considerations
  • Pediatric patients
    • Not “little adults”
  • Geriatric patients
    • Unique subclass of patients with physiological changes complicating treatment
show stoppers
“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 stoppers16
“Show Stoppers”
  • Recent asthma attack or respiratory failure
  • Treatment with MAO inhibitors
  • Tricyclic Antidepressants
  • Adrenal Dysfunction
  • Renal Dysfunction
technician responsibilities17
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
    • Document on AF 1417
      • Clinical Sedation record
technician responsibilities19
Technician Responsibilities
  • Pre-Procedure Patient Assessment
    • Supplemental oxygen applied
    • Suction functioning
technician responsibilities20
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 responsibilities21
Technician Responsibilities
  • Intraoperative Responsibilities – “Float”
    • Vital Signs
      • BP
      • Heart Rate
      • Respiratory Rate
      • Oxygen Saturation
      • Level of Consciousness
technician responsibilities22
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
slide23

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
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
Heart Rate
  • Normal range 60-90
respiratory rate
Respiratory Rate
  • Normal range 10-16 per minute
oxygen saturation
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
Recommended Alarm Limits
          • LowHigh
  • Systolic BP 85 150
  • Diastolic BP 50 100
  • Rate BPM 50 110
  • SP O2 92 100
level of consciousness
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 responsibilities30
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
Movement
  • Move all 4 extremities 2
  • Move 2 extremities 1
  • No control 0
respiration
Respiration
  • Breathe deep and cough 2
  • Dyspnea 1
  • No respirations 0
circulation
Circulation
  • BP +/- 20% pre-sedation level 2
  • BP +/- 21-50% pre-sedation level 1
  • BP +/- > 50% pre-sedation level 0
consciousness
Consciousness
  • Fully alert 2
  • Arousable 1
  • No response 0
color
Color
  • Pink 2
  • Pale, Dusky, Blotchy 1
  • Cardboard 0
the key to sedation
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
Valium (Diazepam)
  • Benzodiazepine
  • Produces sleepiness and relief of apprehension
  • Onset of action 1-5 minutes
  • Half-life
    • 30 hours
    • Active metabolites
  • Average sedative dose
    • 10-12 mg
versed midazolam
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
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
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
Additional Medications
  • Likely to be seen in scenarios where deeper levels of sedation are being performed
    • Propofol (Diprivan)
    • Robinul (Glycopyrrolate)
propofol diprivan
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
Robinul (Glycopyrrolate)
  • Anticholinergic
    • Heart rate increases
    • Salivary secretions decrease
  • Dose 0.1-0.2 mg
  • Onset of action within 1 minute
medical emergency
Syncope

Hypoglycemia

Hypotension

Hypertension

Bronchospasm

Laryngospasm

Apnea

Myocardial infarction

Stroke

Medical Emergency
medical emergency45
Medical Emergency
  • Know when and how to activate a “Code Blue”
  • Location of Crash Cart
    • Medications
    • Monitors
  • Location of emergency medications
  • BLS
medical emergency46
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
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 drugs48
Emergency Drugs
  • Flumazenil (Romazicon)
  • Naloxone (Narcan)
  • Esmolol (Brevibloc)
  • Ephedrine
  • Epinephrine
  • Atropine
flumazenil romazicon
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
naloxone narcan
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
esmolol brevibloc
Esmolol (Brevibloc)
  • Antihypertensive
  • Beta blocker
  • Initial dose 0.25 –1.0 mg/kg over 30 seconds
    • Short half-life of approximately 10 minutes
ephedrine
Ephedrine
  • Used for hypotension
  • Sympathomimetic
  • Initial dose 5-10mg
  • Action may not be seen for several minutes
atropine
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
Epinephrine
  • True emergency medication
  • Administration should be preceded by activation of the 911 emergency response system
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