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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

59 AMDG/Dental Squadron

Technician Orientation Module


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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


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Levels of Anesthesia

  • Local anesthesia

  • Conscious Sedation

  • Deep Sedation

  • General Anesthesia


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Local Anesthesia

  • Elimination of sensations, particularly pain, by the administration of a topical application or regional administration or injection of a drug


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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


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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


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General Anesthesia

  • The elimination of all sensation accompanied by the loss of consciousness


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Stages of General Anesthesia

  • Stage I

    • Analgesia

  • Stage II

    • Delirium

  • Stage III

    • Surgical anesthesia

      • 4 planes of surgical anesthesia


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Stages of General Anesthesia

  • Stage IV

    • Medullary paralysis


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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


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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


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Technician Responsibilities

  • Pre-Procedure

    • Equipment

      • Instruments

      • Venipuncture

      • Monitors

      • Emergency Supplies

        • “Crash Cart”

        • Cardiac Monitor

    • Medications


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Technician Responsibilities

  • Pre-Procedure Patient Assessment

    • Vital Signs

    • Allergies

    • Contacts/Dentures

    • NPO status

    • Changes in medical history

      • URI

      • Hospitalizations

      • Sick family members


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Special Considerations

  • Pediatric patients

    • Not “little adults”

  • Geriatric patients

    • Unique subclass of patients with physiological changes complicating treatment


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“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


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“Show Stoppers”

  • Recent asthma attack or respiratory failure

  • Treatment with MAO inhibitors

  • Tricyclic Antidepressants

  • Adrenal Dysfunction

  • Renal Dysfunction


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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


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Technician Responsibilities

  • Pre-Procedure Patient Assessment

    • Supplemental oxygen applied

    • Suction functioning


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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


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Technician Responsibilities

  • Intraoperative Responsibilities – “Float”

    • Vital Signs

      • BP

      • Heart Rate

      • Respiratory Rate

      • Oxygen Saturation

      • Level of Consciousness


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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


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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


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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


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Heart Rate

  • Normal range 60-90


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Respiratory Rate

  • Normal range 10-16 per minute


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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


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Recommended Alarm Limits

  • LowHigh

  • Systolic BP 85 150

  • Diastolic BP 50 100

  • Rate BPM 50 110

  • SP O2 92 100


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    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


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    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


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    Movement

    • Move all 4 extremities 2

    • Move 2 extremities 1

    • No control 0


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    Respiration

    • Breathe deep and cough 2

    • Dyspnea 1

    • No respirations 0


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    Circulation

    • BP +/- 20% pre-sedation level 2

    • BP +/- 21-50% pre-sedation level 1

    • BP +/- > 50% pre-sedation level 0


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    Consciousness

    • Fully alert 2

    • Arousable 1

    • No response 0


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    Color

    • Pink 2

    • Pale, Dusky, Blotchy 1

    • Cardboard 0


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    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


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    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


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    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


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    Demerol (Meperidine)

    • Narcotic

    • Pain attenuation and some sedation

    • Onset of action

      • 3-5 minutes

    • Half-life

      • 30-45 minutes

    • Average dose

      • 20-50 mg


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    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


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    Additional Medications

    • Likely to be seen in scenarios where deeper levels of sedation are being performed

      • Propofol (Diprivan)

      • Robinul (Glycopyrrolate)


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    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


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    Robinul (Glycopyrrolate)

    • Anticholinergic

      • Heart rate increases

      • Salivary secretions decrease

    • Dose 0.1-0.2 mg

    • Onset of action within 1 minute


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    Syncope

    Hypoglycemia

    Hypotension

    Hypertension

    Bronchospasm

    Laryngospasm

    Apnea

    Myocardial infarction

    Stroke

    Medical Emergency


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    Medical Emergency

    • Know when and how to activate a “Code Blue”

    • Location of Crash Cart

      • Medications

      • Monitors

    • Location of emergency medications

    • BLS


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    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


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    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


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    Emergency Drugs

    • Flumazenil (Romazicon)

    • Naloxone (Narcan)

    • Esmolol (Brevibloc)

    • Ephedrine

    • Epinephrine

    • Atropine


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    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


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    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


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    Esmolol (Brevibloc)

    • Antihypertensive

    • Beta blocker

    • Initial dose 0.25 –1.0 mg/kg over 30 seconds

      • Short half-life of approximately 10 minutes


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    Ephedrine

    • Used for hypotension

    • Sympathomimetic

    • Initial dose 5-10mg

    • Action may not be seen for several minutes


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    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


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    Epinephrine

    • True emergency medication

    • Administration should be preceded by activation of the 911 emergency response system