Intravenous Sedation in Dentistry

Following on from my posts about Inhalation Sedation, let's talk about IV sedation...

Just a recap of the definition of Conscious Sedation from IACSD guidance...

“a technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out, but during which verbal contact with the patient is maintained throughout the period of sedation. The drugs and techniques used to provide conscious sedation for dental treatment should carry a margin of safety wide enough to render loss of consciousness unlikely”

Indications for Sedation

  • Anxiety/phobia​
  • Challenging behaviour/Special Care​
  • Minimise movement (e.g. cerebral palsy)​
  • Unpleasant procedures​
  • Medically compromised​
  • Gag reflex

Why choose IV sedation over IHS?

  1. Deeper level of sedation​
  2. Anterograde amnesic affect - this can be positive for the patient but also a negative as you never really treat a patient's phovia 
  3. Requires less patient cooperation​

    The patient will require an escort, take longer to recover and will have a limited treatment window (typically 30-40 minutes)​

IV Sedation in Dentistry is primarily single drug, midazolam. I discuss more advanced methods of sedation in this blog post. See pros and cons of IV midazolam only sedation below.

Effects of Midazolam

Midazolam is a Benzodiazepine which acts on GABA receptors in the central nervous system which has an antagonist - Flumazenil. This can be admininstered if there is an emergency i.e. oversedation, but also for other reasons such as a special care need, to assist in a difficult journey home or in prolonged recoveries.
  • Anxiolytic ​
  • Sedation​
  • Anticonvulsant​
  • Muscle relaxant​
  • Anterograde amnesia
  • Respiratory Depression

Contra-indications/Cautions of IV Sedation

There are few absolute contra-indications for IV sedation, more so cautions for certain conditions where IV sedation should be avoided if possible, or only carried out in secondary care with an experienced sedationist. For example:
  1. Patient’s allergic to BZD’s​ (absolute)
  2. Chronic airway disorders​ e.g. COPD
  3. ASA grades above III​
  4. Pregnancy (absolute) and breast feeding​
  5. Liver & Kidney disease​
  6. Gross obesity/ High BMI​
  7. Severe psychiatric disease​

    Titration Regime (standard)

2mg of midazolam should be titrated over 30 secs​. You should then wait for 90 secs​ and then increments of 1mg (1 ml) every 30 secs​ until the end-point is reached. 

End-point is when the patient appears relaxed, allows treatment, may have slurred or delayed speech and you will notice a reduction of oxygen saturations. Oxygen saturation and pulse must be monitored continuously to ensure SpO2 remains > 90%. 

This regime may be altered/reduced for certain patient groups e.g. older patients

Post-operative Recovery & Instructions  

Recovery can be in the dental chair or in a specified recovery area​ and patients must be kept monitored both clinically and with pulse ox​imeter. The patient should be encouraged patient to wake up​, but should not leave within hour of last increment of midazolam. Once they are alert and can walk unassisted their cannula can be removed and they can be discharged. 

Post op instructions should be given including:

  • Not to drive a vehicle or ride a bicycle.​
  • Not to operate machinery, including domestic appliances.​
  • Not to attempt to cook, use sharp utensils or pour hot or boiling liquids.​
  • Be cautious of using social media or the internet
  • No alcohol.
  • Not to make any important decisions or sign any contracts.​
  • Not to be responsible for children or other dependants.

Do you have any questions about IV sedation? Please leave them in the comments below

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