PHARMACOLOGIC Means of Patient Management

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PHARMACOLOGIC

MEANS OF

PATIENT

MANAGEMENT


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TERMINOLOGIES

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ADA (1993) has defined as: CONSCIOUS SEDATION: a minimally depressed level ofconsciousness, that retains the patients ability to maintain anairway independently & respond appropriately to physical

stimulation & verbal command DEEP SEDATION: a controlled state of depressed consciousness,accompanied by a partial loss of protective reflexes, includinginability to respond purposefully to a verbal command


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GENERAL ANAESTHESIA: a controlled state ofunconsciousness, accompanied by partial or complete lossof protective reflexes, including inability to maintain anairway independently & respond purposefully to physicalstimulation or verbal command AMBULATORY, OUTPATIENT OR DAY CAREANAESTHESIA: refers to the delivery of anesthetic carein which patients are discharged home on the day oftreatment.


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ROUTES OF SEDATION

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INHALATION: nitrous oxide sedation

ORAL SEDATION: Hydroxyzine, Promethazine, Chloral

hydrate, Meperidine, Diazepam, Triazolam, Chlorpromazine

INTRAMUSCULAR: Ketamine, Midazolam

INTRAVENOUS SEDATION: Midazolam


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CONSCIOUS SEDATION

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Techniques that uses drugs to inducecooperative yet conscious state in uncooperativepatient are referred to as TECHNIQUES OFCONSCIOUS SEDATION

OBJECTIVES: Benett(1978) stated: Patients mood should be altered Should be conscious, respond to verbal stimuli Should be co-operative Intact Protective reflexes

Vital signs stable & normal Pain threshold should be increased Amnesia should occur


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INDICATIONS:Who cant cooperate or understand for

definitive treatmentLacking cooperation because ofpsychological or emotional maturity

Patient with dental care requirements butare fearful & anxious

CONTRAINDICATIONS:COPD, pregnancy, myasthenia, epilepsy,

bleeding disordersunwilling, unaccompanied patientDental difficulties prolonged surgery,

inadequate personnel


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NITROUS OXIDE-O2 MIXTURE

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Widely used for conscious sedationAdvocated by Roberts in 1990


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NITROUS OXIDE & OXYGEN

SEDATION

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Most frequently used sedative agent; 85%

Slightly sweet smelling, colorless, inert gas

Compressed in cylinders as liquid that vaporizes

on release Non inflammable; support combustion


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Stages of anesthesia

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PHASE 1 ( MODERATE SEDATION &ANALGESIA)Achieved with conc of 5-25% N2O2 (95-75%)Symptoms are explained to the child:

floating, light feeling

May sense dizzinessTingling in fingers, toes, tongue, cheeks,

back, headMarked sense of relaxation

Relaxed perioral musculatureDiminution of fear & anxiety


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PHASE 2 (DISSOCIATION SEDATION & ANALGESIA)Conc 25-45%Dissociation/ detachmentLevel of psychosedationReduced blink rateConscious & responds, with considerate effort

PHASE 3 (TOTAL ANESTHESIA/ANALGESIA)Conc 45-65%Analgesia is completeMarked amnesia

PHASE 4Beyond 65-85%LIGHT ANESTHESIAContact with patient is lost


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DEEP SEDATION

&

GENERAL ANAESTHESIA

Incomplete, partial or total loss of protective

reflexes Partial or complete loss of ability to

independently & continuously maintain patent

airway

Requirements & management of unconsciouspatient address greater concern for safety


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INDICATIONS

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Patients with certain physical, mental ormedically compromising condition

Wherein local anesthesia is not effective

or patient is allergic to it Fearful, uncooperative, anxious patient

with no expectation that behavior will

improve Patients with dental needs who would

receive comprehensive dental care eg

rural areas


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REQUISITES

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Knowledge of agent & method ofadministration

Carefully planned & documented

rationale for use of sedation Evaluation to ensure no risk to patient

Well documented informed consent

Proper office facilities with no physicalbarriers & proper equipments

Mobile emergency services


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PRE MEDICATION

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ANTI-CHOLINERGICSAtropine, glycopyrrolate

SEDATIVES

For apprehensive patient

Benzodiazepines, barbiturates

ANTI-EMETIC

Anti histamines ( Hydroxyzine)


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INTRAVENOUS INDUCTION

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Thiopental sodium Rapid onset of action & recovery

Application of topical agent

Pre oxygenation 2.5% of Thiopental sodium injected as test

dose

2.5% every 15sec upto 0.5g & .2-.25mg in

child Rapid induction cause involuntary movements

Contraindicated in: respiratory obstruction,shock, severe asthma, porphyria


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INHALATION

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Maintenance of anesthesia

Classified as Volatile, Gaseous

Divinyl ether, diethyl ether, halogenated

hydrocarbons

Masks are used


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Chairside General Anesthesia

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Day care, office or ambulatory anesthesia ASA I or II patients taken up, procedure taken upon OPD basis, & patient discharged the same day.

Depending on recovery, patient may have to makean overnight stay


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ANATOMIC & PHYSIOLOGIC

DIFFERENCES

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Regimen of conscious sedation varies for pediatric patient,

because:

Difference in size, weight & age as a measure of

maturation systems

Difference in BMR

Respiratory rate is higher in children


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AIRWAY MANAGEMENT

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Greater risk of airway obstruction; narrow nasalpassages & glottis, hypertonic tonsils & adenoids,

enlarged tongue & greater secretions

Sudden apnea; reduced tolerance to obstruction

Less functional reserve; smaller thorax


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CARDIOVASCULAR

PARAMETERS

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Faster heart rate

Lower BP

More susceptibility to bradycardia, lower cardiac

output & hypotension


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POST OPERATIVE

MONITORING

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Before discharging patient, all vital signs must bestable

Child must be alert, able to talk, sitting unaided

For very young & disabled children, a level of

awareness as close to usual state must beachieved before discharge

Monitored at frequent & regular intervals

PHARMACOLOGIC Means of Patient Management

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