Conscious sedation for dentistry 2nd edition

www.pdflobby.com www.pdflobby.com Conscious Sedation for Dentistry www.pdflobby.com www.pdflobby.com Conscious Sedation for Dentistry Second Edition N M Girdler Newcastle University School of Dental Sciences UK C M Hill Cardiff University School of Dentistry UK K E Wilson Newcastle University School of Dental Sciences UK www.pdflobby.com This edition first published 2018 © 2018 John Wiley & Sons Ltd Edition History © 2009 N M Girdler, C M Hill, K E Wilson All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions The right of N M Girdler, C M Hill, and K E Wilson to be identified as the authors of this work has been asserted in accordance with law Registered Office(s) John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial Office 9600 Garsington Road, Oxford, OX4 2DQ, UK For details of our global editorial offices, customer services, and more information about Wiley products visit us at www.wiley.com Wiley also publishes its books in a variety of electronic formats and by print‐on‐demand Some content that appears in standard print versions of this book may not be available in other formats Limit of Liability/Disclaimer of Warranty The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work The fact that an organization, website, or product is referred to in this work as a citation and/ or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make This work is sold with the understanding that the publisher is not engaged in rendering professional services The advice and strategies contained herein may not be suitable for your situation You should consult with a specialist where appropriate Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages Library of Congress Cataloging‐in‐Publication Data Names: Girdler, N M., author | Hill, C M., author | Wilson, K E author Title: Conscious sedation for dentistry / N M Girdler, C M Hill, K E Wilson Other titles: Clinical sedation in dentistry Description: Second edition | Hoboken, NJ, USA ; Chichester, West Sussex, UK : John Wiley & Sons Ltd., 2017 | Preceded by: Clinical sedation in dentistry / N.M Girdler, C Michael Hill, Katherine Wilson Chichester, West Sussex : Wiley-Blackwell, 2009 | Includes bibliographical references and index Identifiers: LCCN 2017014485 | ISBN 9781119274476 (pbk.) Subjects: | MESH: Conscious Sedation | Anesthesia, Dental Classification: LCC RK510 | NLM WO 460 | DDC 617.9/676–dc23 LC record available at https://lccn.loc.gov/2017014485 Cover design: Wiley Cover image: (Background) barbaliss/Shutterstock; (Photos) Courtesy of N M Girdler, C M Hill, and K E Wilson Set in 10/12pt Warnock by SPi Global, Pondicherry, India 10 9 8 7 6 5 4 3 2 1 www.pdflobby.com v Contents About the Companion Website  vii Spectrum of Anxiety Management  Applied Anatomy and Physiology  13 Patient Assessment  35 Pharmacology of Sedation Agents  51 Premedication, Oral and Intranasal Sedation  67 Principles and Practice of Inhalation Sedation  71 Principles and Practice of Intravenous Sedation  91 Complications and Emergencies  113 Sedation and Special Care Dentistry  133 10 Medico‐Legal and Ethical Considerations  141 Index  151 www.pdflobby.com www.pdflobby.com vii About the Companion Website Don’t forget to visit the companion website for this book: www.wiley.com/go/girdler/conscious_sedation_dentistry There you will find valuable material designed to enhance your learning, including: ●● Multiple choice questions and answers Scan this QR code to visit the companion website www.pdflobby.com www.pdflobby.com Medico-Legal and Ethical Considerations Expert Advice Patients also have the right to expect expert advice Because of the privileged nature of the dental profession and its protected status in law, patients must be given appropriate, accurate and current information regarding any condition they have or treatment they are to receive This can only be achieved by practitioners keeping up to date with modern developments through education and self‐improvement Where a dentist is unable to provide accurate details on a relevant subject the information should be obtained from a third party Quality Care This combination of expert advice based on safeguarding the patient’s health as a primary responsibility, should automatically lead to the third area of expectation – the receipt of quality care Quality care is difficult to define but readily understandable It is the prospect of having treatment which will be both effective and durable There can be little doubt that the majority of all dental treatment performed in the UK fits the above criteria but there are times when this is not the case On occasion this may be due to inadequate treatment or failed materials and sometimes it is due to mistakes being made The law does not deny the likelihood of mistakes occurring but it does expect mistakes to be corrected and patients can expect the support of the law in this regard The question as to whether a ‘mistake’ is of such severity that it would be considered negligent is not the same issue The primary question in law to be answered first is whether the practitioner making the mistake was using reasonable skill when the accident occurred, and second, was the opportunity given to remedy the error Many cases have been lost by plaintiffs on this latter point Plaintiffs in negligence cases also have a duty to submit themselves for examination by an expert witness for the defence, if required so to This is supposed to prevent the malicious pursuit of a claim against a practitioner when, if such access was not agreed, the patient could effectively frustrate a reasonable defence The same principle would apply to any medical records held on behalf of a patient which may relate to an incident and these can be requested by the defendant or the plaintiff ­Duties and Responsibilities of the Dentist Direct Patient Care The converse of the above section clearly applies In delivering care to a patient, the dentist must safeguard: ●● ●● ●● ●● The patient’s health Provide the patient with expert information Deliver quality care Remedy any mistakes that may occur www.pdflobby.com 143 144 Conscious Sedation for Dentistry A dentist does not have to conform to a single opinion with reference to a particular technique, method or procedure There may even be disagreements on the matter of diagnosis and again this possibility is recognised by the courts The dentist has an absolute duty to obtain the consent of a patient before undertaking any procedure Failure to so may constitute assault and battery although, in reality, charges of this nature are usually rejected by the courts in favour of negligence claims The question of consent is extensive and is dealt with later in this chapter Record Keeping In addition to the legal constraints outlined above, the dentist also has other duties that would reasonably be expected of a professional These include, for example, keeping good, accurate and contemporaneous records This is a common area of inadequacy and one that is frequently compounded by the retrospective addition of notes when problems occur These are normally added in an attempt to clarify details but they have little standing in law and can make the defence of a case untenable Notes must, therefore, be made as contemporaneously as possible but never to the detriment of clinical practice The notes made by a dentist and all the other information gathered about patients is confidential and there are very few occasions when it can be legally disclosed without the patient’s consent The right of confidentiality is well understood in law and can only be breached in well‐defined circumstances Dental records must therefore be kept promptly, accurately and confidentially Legal and Professional Restraints The final area of responsibility of a dentist is that of observing legal and professional restraints The law may influence clinical practice in a variety of ways, some obvious and some remote The law exists to protect the patient and its influence is profound, perhaps no more so than in the Dental Act which gives statutory powers to the General Dental Council (GDC) In other countries, other regulatory bodies exist with varying degrees of power In the United Kingdom, however, the GDC issues professional guidance and with regard to sedation its recommendations are quite specific The dentist has a duty to observe the guidance given by the council and failure to so may result in a charge of professional misconduct and the dentist will have to provide answer to any such charges On a more positive note, however, the GDC provides professional recognition for the dentist and it has enormous powers to stop the misappropriate use of dentistry Further restraints and guidance can be imposed by many authorities including the fire services, the Health and Safety Executive, and other similar bodies It behoves each member of the dental practice to be aware of the prevailing conditions and to pay due attention to their requirements ­Criminal and Civil Charges The terms assault and battery are frequently used and poorly understood Assault is technically the threat of violence against a person rather than the act of violence itself Battery may be defined as any unwarranted physical contact but usually refers to an act www.pdflobby.com Medico-Legal and Ethical Considerations that ­violates somebody A person cannot be guilty of battery if they can prove that the contact was entirely accidental or that they were acting with the plaintiff ’s agreement In some medico‐legal cases some plaintiffs have tried to bring criminal proceedings, claiming assault and battery based on technical questions of consent, but this has rarely been successful The courts have usually decreed that claims for medical accidents should be heard under charges of negligence, that is, as a civil claim rather than a ­criminal offence This may have some advantages, but for a patient, it does mean that until they go to court and successfully prove that negligence has occurred, it is impossible to know whether they are entitled to any compensation To successfully prove negligence, a plaintiff must show: 1) that a duty of care was owed 2) that the duty of care was breached 3) that the breach in care resulted in harm to the patient Patients usually have no problem in proving the duty of care was owed but to s­ imultaneously prove points and above is not always easy This sometimes leads to decisions that, to say the least, seem arbitrary In some cases, the question of negligence is highly controversial and the court system is both expensive and unpredictable Because of this there has been a considerable amount of criticism of the litigation system, and in some countries ‘no‐fault’ compensation schemes exist for medical accidents, where compensation is awarded on fixed scales of payments but where the plaintiff does not have to prove negligence after a medical accident to get compensation It could be argued that such a scheme is preferable, although there are also opponents to such systems who argue that it could lower professional standards ­Consent Patients have a fundamental legal and ethical right to determine what happens to their own bodies Valid consent to treatment is therefore absolutely central in all forms of health care, from providing personal care to undertaking major surgery Consent in the medical context is a patient’s agreement for a health professional to provide care Patients may indicate consent non‐verbally (for example by presenting their arm for their pulse to be taken), orally, or in writing For the consent to be valid, the patient must: ●● ●● ●● be competent to take the particular decision have received sufficient information to make an informed choice not be acting under duress A person may choose without undue pressure to give or withhold consent to any examination, investigation or treatment as a matter of choice If a patient has given his or her consent to a procedure being undertaken, there can be no grounds for bringing a charge of battery (although they may still be able to claim the breach of negligence) In a court of law, therefore, the issue is simply one of whether a patient had consented, and the practitioner has to be able to demonstrate that this was the case www.pdflobby.com 145 146 Conscious Sedation for Dentistry Demonstrating Consent On occasion, this may be possible simply by referring to the actions of the patient, for example, lying in a dental chair and opening one’s mouth is almost certainly sufficient evidence of a patient consenting to an oral examination No written signature is necessary in such cases but conversely, a signature obtained on an illegible consent form is unlikely to be acceptable evidence of consent in complex restoration cases carried out under intravenous sedation This is because the dentist has a duty of care to the patient to explain, in such a way that the patient understands the nature of the procedure being proposed, its associated risks and benefits and any possible alternative treatments Modern consent forms nearly always include a section that is signed by practitioners certifying that they have explained the details to the patient Even so, it should be remembered that the ­consent form in itself is not necessarily sufficient evidence of consent being obtained Patient Information A high‐profile case (NM vs Lanarkshire 2015) enforces the need for doctors and dentists to ensure they gain informed consent from patients prior to carrying out treatment The case describes NM, the mother of a child born with cerebral palsy, who sued Lanarkshire Health Board arguing that her consultant should have warned her about the risks to her and her baby of shoulder dystocia (a mechanical problem) occurring during delivery She also argued that her consultant should have informed her of the alternative delivery option of a caesarean section, which would have avoided the risks and the subsequent injury to her child In defining how much information a patient should be given, this case concluded: Fundamental to the doctor and patient relationship is the requirement that a patient with capacity to decide should be informed about the treatment options open to him or her; the risks and benefits of each option; and be supported to make their choice about which treatment best meets their needs In essence, this reinforced the judgement given in another famous case (the Sidaway case) where the judgment set out the principle of providing enough information to make an informed choice In practical terms, dentists will have to decide the extent of information provided in relation to each patient but should bear in mind the need to be as complete and as unbiased as possible Patient Age The question of a person’s age is also relevant to the laws of consent The law defines adulthood from the date of a person’s eighteenth birthday From that age, providing they have the capacity to make decisions on their own behalf, people are said to be competent To be deemed competent, an adult must be able to: ●● ●● ●● ●● understand the proposed treatment in relation to its benefits and risks understand the alternative treatments available understand the consequences of not accepting the proposed treatment retain the relevant information long enough to make a free decision, that is, with no external pressure from any interested party www.pdflobby.com Medico-Legal and Ethical Considerations The law is complicated for children between the ages of 16 and 18 years and even more so for those under 16 years In essence, however, the same general principles hold true for children when they consent (agree) to treatment In the past, it has been traditional to ask parents to sign consent on behalf of their children under the age of 16 but, in law, children may now legally sign consent for both surgery and sedation if they are competent to so The age at which they become competent is not defined but it can no longer be set rigidly at age 16 If children refuse to consent to treatment, however, their parents may well have a legal right to overrule their refusal This is unquestionably so with young children but must be exercised with progressive caution as children get older The same rights can be given to the courts in making a child a Ward of Court but such actions need to be taken with some sensitivity Consent may also be given by legal guardians, adoptive parents and the local authorities for children who are the subject of a care order Capacity to Consent Finally, the hardest area in the question of consent is probably in relation to those adult patients who are not deemed competent At the current time, nobody can authorise consent on behalf of an incompetent adult (except in cases where they have predetermined it by an advanced power of attorney) and doctors and dentists must act in their patient’s best interests, wherever possible obtaining two independent professional views as to the advisability of any proposed treatment A record should be made of the assessment of the patient’s capacity, why the health professional believes the treatment to be in the patient’s best interests, and the involvement of people close to the patient The practitioner’s overriding responsibility is the duty of care which is owed to the patient and, if necessary, this should be demonstrable to a court of law Parents may give consent on behalf of children between the ages of 16 and 18 years when the child is not deemed competent to so The law on these matters is governed by Mental Capacity Act 2005 (England and Wales), Adults with Incapacity Act (2000) Scotland and expert opinion should be sought in any case likely to be contentious Assessing Capacity to Give Consent As an example, the Mental Capacity Act for England and Wales (2005) in dealing with the issue of capacity states that: ●● ●● ●● ●● ●● A person must be assumed to have capacity unless it is established that they lack capacity A person is not to be treated as unable to make a decision unless all practicable steps to help them to so have been taken without success A person is not to be treated as unable to make a decision merely because they make an unwise decision An act done or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in the patient’s best interests Before the act is done, or the decision is made, regard must be taken as to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action www.pdflobby.com 147 148 Conscious Sedation for Dentistry In assessing a person’s capacity, the following factors must be met: ●● ●● ●● Can the patient understand and retain the relevant treatment information? Does the patient believe it? Can the patient weigh the information in the balance to arrive at a choice? If the patient fails to meet any of these tests he or she will lack capacity and the clinician treating the patient can act in the best interests of the patient The situation in Scotland differs in that, where an adult lacks capacity to consent (other than in an emergency, or where there is a proxy decision maker), a certificate of incapacity must be issued to provide care or treatment ­Risk Assessment Risk assessment is essentially a management tool, used to minimise the incidence of untoward events, but it can be applied to clinical situations with great effect It is a process which should be proactive and not reactive, in other words, it should attempt to stop mistakes before they happen rather than using the mistakes themselves as the drivers of change Areas to be considered in a risk assessment include information and consent, staff training issues, referral mechanism, standardised procedures, and standard facilities, among others Risk assessment should be dealt with systematically and repeated periodically Any problems identified should be addressed and solutions put in place which should themselves be assessed after a period of time All staff members must be included in the process and encouraged to strive for continued improvement in standards ­Dealing with Sedation‐Related Incidents The incidence of complications from patients undergoing simple sedation for dental treatment is extremely low However, there have been reports of critical episodes, some of which have led to serious morbidity In such cases there will be a sequence of procedures to be followed and questions to be asked The purpose of this is to establish: 1) What went wrong and why did it go wrong? 2) Had a proper pre‐assessment procedure been followed? 3) Was the sedation technique used justifiable and correctly administered by a competent person? 4) Were the appropriate support staff available at all times? 5) Was a correct resuscitation procedure followed by staff who knew and performed their duties, and were all the necessary drugs and equipment available? If the dentist can give reasons, for the first question and answer the remaining questions positively, there will be little cause for concern If not, the failings need to be identified so that the courts can determine a verdict in relation to the adverse event Everyone concerned with the practice of sedation must ensure that it is a safe, efficient and effective procedure that is undertaken for the benefit of the patient In the vast majority of cases this will be beyond doubt; in the few cases where mishaps occur, careful www.pdflobby.com Medico-Legal and Ethical Considerations and prompt management should ensure that a minor problem does not become a clinical or a legal catastrophe For most patients, conscious sedation enables them to undertake dental treatment which they would at best find uncomfortable and at worst, impossible For the dentist, it offers a set of tools that can aid in treatment provision and general patient management Reference Mental Capacity Act 2005 Online at: www.legislation.gov.uk/ukpga/2005/9/contents (Accessed June 2017) Further Reading Department of Health (2001) Good Practice in Consent Implementation Guide: Consent to Examination or Treatment London, HMSO Johnston, C & Liddle, J (2007) The Mental Capacity Act 2005: a new framework for healthcare decision making Journal of Medical Ethics, 33(2), 94–97 Scottish Government (2000) Adults with Incapacity (Scotland) Act 2000 Online at: http:// www.legislation.gov.uk/asp/2000/4/contents (accessed 12 April 2017) www.pdflobby.com 149 www.pdflobby.com 151 Index Page numbers in italics represent figures, those in bold represent tables a acute chest pain  129 adenosine triphosphate (ATP)  28 adrenal insufficiency  41 adrenal shock  128 age see patient age airway management  115–17 independent oxygen supply  115 intermittent positive pressure device 116–17, 116 nasopharyngeal airways  115–16, 116 oral airways  115, 115 suction equipment  117 airway obstruction  122–3 anaemia 41 analgesia, planes of  72–4, 72 anaphylaxis 127–8 anatomy 13–32 angina 129 antecubital fossa  21 anxiety 2 aetiology 2–4, dental treatment factors  family/peer group influences  gender 3 psychological development  traumatic dental experience  measurement 4–5, nature of  36 physiological responses  psychological responses  anxiety management  1–12 anxiety scales  5, arteries 13, 14 aspirin  118, 119 asthma  39, 129 atrioventricular node  16 attention deficit hyperactivity disorder (ADHD) 137 autism 137 automated external defibrillator  114 b baroreceptors 19 basic life support  125 behavior 6 nature of  6, behaviour management  6–10 hypnosis 10 permissible deception  7–9 positive distraction  6, relaxation techniques  systematic desensitisation  tell, show, do  7, benzodiazepines 58–61 clinical effects  59 inappropriate administration  60–1 pharmacokinetics 58–9 side effects  60 see also individual drugs best interests  142 Conscious Sedation for Dentistry, Second Edition N M Girdler, C M Hill and K E Wilson © 2018 John Wiley & Sons Ltd Published 2018 by John Wiley & Sons Ltd Companion website: www.wiley.com/go/girdler/conscious_sedation_dentistry www.pdflobby.com 152 Index blood pressure  18, 18, 44–5, 45 control of  19 hypertension 19–20 hypotension 20 importance in dental patients  20 monitoring 105, 106 body mass index  45–6 bradycardia 17–18 bronchi 22, 23 bronchioles 24, 23 c cannulation 99–101, 99–101 capacity 147–8 capillaries 14 carbon dioxide  19, 25 exchange 28–9 cardiac arrest  124–5 cardiac cycle  15–16 cardiac output  15–16 cardiovascular disease  39 cardiovascular system  13–20 see also individual parts cerebral palsy  137 cerebrovascular accident  129–30 chlorphenamine maleate  118 choking 122–3 civil charges  144–5 civil system  141–2 complications 113–31 inhalation sedation  86, 87, 88 intravenous sedation  111 local complications  130–1 conscious sedation see sedation consent  49–50, 145–8 capacity 147–8 patient age  146–7 patient information  146–7 criminal charges  144–5 criminal system  141 d day‐stay setting  135–6, 136 defibrillation 120, 120 dental anxiety see anxiety dental history  36 dental treatment factors  dental treatment plan  47 dentist, duties and responsibilities  143–4 direct patient care  143–4 legal and professional restraints  144 record keeping  144 dextrose 119 diabetes 41 diazepam 61, 61, 64, 92 premedication 67 diffusion hypoxia  54, 85 direct patient care  143–4 Down syndrome  137 drug interactions  42, 42, 123 e emergencies medical see medical emergencies sedation‐related 120–4 airway obstruction  122–3 drug interactions  123 exacerbation of medical condition 121 hypotension 123 loss of consciousness  124 respiratory depression  122 vasovagal attack  121–2 emergency drugs  117–20, 118, 118 emergency equipment  114, 114 endocrine disease  40–1 endothelium‐derived relaxing factor  17 epilepsy 128 epinephrine  118 equipment emergency 114, 114 inhalation sedation  76–81 checks 80–1 free‐standing units  76–7, 77 gas delivery system  79–80, 80 piped gas unit  77, 78 reservoir bag  79, 79 safety features  80 sedation head unit  77–8, 78 intravenous sedation  95, 95 emergency 94 monitoring 94 Eve’s sign  103 expert advice  143 www.pdflobby.com Index expiration 26 extravenous injection  130 f fainting  121–2, 125–6 fear 1 fight or flight response  flumazenil 62–3, 62, 64, 118, 120 g GABA 58, 59 gas solubility  27, 52–3, 52 gender, and anxiety levels  general anaesthesia  11 General Dental Council  10 glucagon  118, 119 glucose  118, 119 glyceryl trinitrate  118, 119 Guedel airway  115, 115 h haematological disorders  41 haematoma, post‐operative  131 half‐life alpha 30 beta 31 heart 15, 15 cardiac cycle  15–16 conduction system  16–17, 16 heart rate  15, 17–18, 17, 44–5 history taking  35–7 Huntington’s disease  136 hydrocortisone hemisuccinate  118 hypertension 19–20 hypnosis 10 hypoglycaemia 127 hypotension  20, 123 i infusion pumps  64 inhalation agents  52–7 circulation to tissues  28 gas solubility and partial pressure 52–3, 52 lung entry  26–7 nitrous oxide  53–6, 54–5 oxygen 57 potency 53 sevoflurane 56–7 inhalation sedation  71–88 advantages 75 chronic effects  88 contraindications 74–5 disadvantages 75 discharge 86, 86 equipment 76–81 checks 80–1 free‐standing units  76, 77 gas delivery system  79–80, 80 piped gas unit  76, 78 reservoir bag  79, 79 sedation head unit  77–8 indications 74–5 monitoring 85 patient management  83–5, 83, 84 patient preparation  75–6 planes of analgesia  72–3, 72 pre‐operative checks  81–3, 82 records 86, 87 recovery 85 safety and complications  86–8 see also inhalation agents inspiration 25–6 intellectual impairment  43 see also special care dentistry intermittent positive pressure device 116–17, 116, 117 intra‐arterial injection  130 intravenous agents  30–2, 57–65 benzodiazepines 58–63 distribution  32 elimination 31 excretion 31 flumazenil 62–3, 62 induction 57 onset of action  31 recovery  31–2, 58 redistribution 30–1 intravenous sedation  91–111 advantages 93 blood pressure monitoring  105–6, 106 cannulation 99–101, 99–101 clinical effects  93 clinical monitoring  103 www.pdflobby.com 153 154 Index intravenous sedation (cont’d) complications 111 contraindicatons 92 dental treatment  105–6 disadvantages 93 drug choice  92–3 electromechanical monitoring  103 emergency equipment/drugs  94 equipment 94–5, 95 indications 91–2 oxygen desaturation  104–5, 105 personnel 93–4 planning for  93–5 pre‐procedural checks  95–7, 96 pulse oximetry  104, 105, 104 records 109–11, 110 recovery 106–9, 107, 109 recovery facility  94 titration of sedation agent  101–3, 102, 103 venepuncture 97–8, 98 see also intravenous agents l Langa, Harold  71 larynx 22, 23 legal and professional restraints  144 legal system  141–2 civil system  141–2 criminal system  141 liver disease  40 loss of consciousness  124 lungs carbon dioxide exchange  28–9 oxygen exchange  28–9 volumes 26, 27, 27 see also respiration; respiratory m medical emergencies  124–9 acute chest pain  129 adrenal shock  128 anaphylaxis 127–8 asthma  39, 129 cardiac arrest  124–5 cerebrovascular accident  129–30 epilepsy 129 hypoglycaemia 127 vasovagal syncope  125–6 medical history  36–7 medico‐legal considerations  141–9 consent 145–8 criminal and civil charges  145 duties and responsibilities of dentist  143–4 rights and responsibilities of patients 142–3 risk assessment  148 sedation‐related incidents  148–9 United Kingdom legal system  141–2 Mental Capacity Act (England and Wales)  2005, 147 mental health problems  138–9 metabolism 31 midazolam 62, 62, 64, 92, 118, 119 clinical effects  93 dose titration  101–3, 101, 103 oral sedation  69 monitoring blood pressure  105, 106 electromechanical 103 inhalation sedation  85 intravenous sedation  103 musculoskeletal disorders  137–8 mutiple sclerosis  136 n nasopharyngeal airways  115–16, 116 needle phobia  74, 92 neurological conditions  40, 136–7 nitrous oxide  27, 28, 53–6 blood/gas solubility  54 occupational hazards  55–6, 54, 56 potency 55 presentation 54, 54 scavenging 88 sedative effects  55 see also inhalation sedation o oral airways  115, 115 oral examination  44 oral sedation  68–9 www.pdflobby.com Index out‐patient setting  135 oxygen 57, 118, 118–19 availability  29 desaturation 104–5, 105 exchange 28–9, 29 independent supply  115 saturation  25, 45 oxygen/haemoglobin dissociation curve  29 physiology 13–32 pregnancy 42–3 premedication 67–8 pre‐operative checks  81–3, 82 propofol 63–5, 64 psychological development, and anxiety 2 pulse oximetry  104, 104 alarm 105 p q paradoxical respiration  26 Parkinson’s disease  136 partial pressure  52–3, 52 patient age  43, 146–7 patient assessment  35–50 age  43, 146–7 clinical examination  44 consent 49–50 drug therapy  42, 42 fitness for sedation  37–9 history taking  35–7 intellectual or physical impairment  43 oral examinaton  44 pregnancy 42–3 preparation for sedation  47–50, 48 records 86, 49 setting 35 social circumstances  43 specific medical conditions  39–43 treatment planning  46–7 vital signs  44–6 patient preparation  75–6 patients, rights and responsibilities  142–3 best interests  142 expert advice  143 quality care  143 peer group influences  permissible deception  7–9 personnel 93–4 pH 25 pharmacodynamics 32 pharmacokinetics 32 phobia 2 physical impairment  43 see also special care dentistry quality care  143 r record keeping  50, 49, 144 inhalation sedation  86, 87 intravenous sedation  109–11, 110 recovery inhalation sedation  85 intravenous sedation  106–8, 107, 109 recovery facility  94 relative analgesia  71 relaxation techniques  renal disease  40 respiration 24 control of  24–5, 24 expiration 26 inspiration 25–6 paradoxical 26 respiratory depression  122 respiratory disease  39–40 respiratory system  22–9 lower airway  22, 23 upper airway  22, 23 see also lungs Resuscitation Council  114 risk assessment  148 s salbutamol  118, 119 sedation 51–65 assessment see patient assessment choice of technique  46–7 consent 49–50 current United Kingdom practice  10 definition 10 fitness for  37–9 www.pdflobby.com 155 156 Index sedation (cont’d) inhalation agents  52–7 intravenous  30–2, 57–65 oral 68–9 patient preparation  47–50, 48 vascular anatomy of upper limb  20–2, 21 sedation‐related incidents  148–9 sensory impairment  138 sensory nerves  19 sevoflurane 56–7 sinoatrial node  16 social circumstances of patients 43 special care dentistry  133–9 day‐stay setting  135–6, 136 out‐patient setting  135 patient groups learning disability  137–8 mental health problems  138–9 musculoskeletal disorders  137 neurological conditions  136–7 sensory impairment  138 status asthmaticus  129 stroke volume  15 suction equipment  117 systematic desensitisation  t tachycardia 17 temazepam oral sedation  69 premedication 68 thyroid disorders  41 trachea 22, 23 traumatic dental experience  tunica adventitia  14 tunica intima  14 tunica media  14 u upper limb, vascular anatomy  20–2, 21 v Valium see diazepam; and benzodiazepines vasovagal attack  121–2, 125, 126 veins 14, 14 venepuncture 97–8, 98 venous access  97–8, 98 Verill’s sign  102 visual analogue scales  5, vital signs  44–6 w Wells, Horace  53 www.pdflobby.com WILEY END USER LICENSE AGREEMENT Go to www.wiley.com/go/eula to access Wiley’s ebook EULA www.pdflobby.com ...www.pdflobby.com Conscious Sedation for? ?Dentistry www.pdflobby.com www.pdflobby.com Conscious Sedation for Dentistry Second Edition N M Girdler Newcastle University... provision of conscious sedation in dental practice More recently in 2015 the Intercollegiate Advisory Committee for Sedation in Dentistry (IACSD) published Standards for Conscious Sedation in... www.wiley.com/go/girdler /conscious_ sedation_ dentistry www.pdflobby.com 36 Conscious Sedation for Dentistry current dental symptoms, a thorough medical history and information on social circumstances