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