What is Advanced Sedation....?
You may be aware of some forms of sedation for helping patients manage dentistry... but what about advanced techniques?
Why Would You Need an Advanced Technique?
The majority of IV sedation in dentistry is provided with a single drug: Midazolam. This a very effective and safe drug to use, so why might we need to consider other options?
- For very long, or very short procedures - The sedation window with midazolam can vary per individual, but typically you can get 30-40 minutes of good quality sedation to carry out your treatment. But what if your procedure takes longer than this... like endo, or placement of an implant? Your patient might not be sedated towards the end of your treatment, which could lead to a bad experience for them. Or what if you need to do a very short procedure? Like extraction of mobile teeth? Then you have to recover the patient for a long time, when your treatment took 5 minutes. In these cases an option could be an advanced technique (or the other option is inhalation sedation), where you can continually give the patient a sedative drug which has a very short half-life e.g. Propofol
- Where single use drug does not give enough sedation to carry out the treatment, or the dose of midazolam would be really high
- Where there has been a bad reaction to midazolam sedation in the past, and the patient might prefer a technique which gives them more control and awareness e.g. Propofol
What Drugs are used?
1. Propofol
Propofol is the milky white drug that is associated with the death of Michael Jackson. Propofol is a anaesthetic agent, but if given in smaller doses, is a useful sedative drug:
- Propofol has a very short half life of 4 minutes, which allows for a very fast recovery and means it has to be continually infused throughout treatment. This means you can control the length of the procedure and can be useful in very short or longer treatments
- Propofol is contraindicated in patients with epilepsy as there are cases where it has induced seizures. It is also contraindicated in patients with soy or egg allergies
- Propofol gives a different sedative effect for patients which is more anxiolytic
- It has less respiratory depressant effect than midazolam so may be a safer choice in patients with respiratory or airway issues
2. Opioids
Opioids such as Fentanyl can be used in sedation, which are often used in combination with other drugs (see below). Using opiods can be useful as together with their sedative properties, they have analgesic effects.
3. Ketamine
Most commonly used as a IM injection for patients with limited cooperation or as a premedication (children or patients with learning disabilities). Ketamine has the advantage of not causing significant depression of the respiratory drive and produces significant bronchodilation secondary to sympathetic stimulation. While ketamine does not prevent obstruction and airway compromise in an unconscious patient, airway reflexes tend to be better preserved than with other induction agents
Multi-drug Sedation
The drugs above can be used in isolation for sedation, but can also be used in combination. This decreases the margin of safety of the drugs so there are greater risks associated e.g. for Fentanyl + Midazolam this increases respiratory depression 6 fold! This can reduce the total dose of midazolam for example for patients who would need large doses. Examples of multi-drug regimes include:
- Midazolam + Propofol. Midazolam bolus then titration of propofol
- Fentanyl + Midazolam. Fentanyl bolus then midazolam titration as normal
- Propofol + Opioid
IV Sedation in Children under 16s
The first line option for sedation in children is usually inhalation sedation with nitrous oxide, but in some cases, the use of IV drugs is appropriate. In order to provide any of these advanced techniques you will require further training. To read more about the guidance surrounding this check out this previous blog post I did here.
Although there are advanced sedation techniques out there, remember that 95% of patients can be treated with one sedation drug alone (i.e. midazolam or nitrous oxide). Keep an eye out for other sedation blog posts coming shortly!
0 comments