PHARMACOLOGIC Means of Patient Management
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Transcript of 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