In: Dental treatment4 Dec 2009
All patients in this study were American Society of Anesthesiologists Category 1 and Category 2 patients undergoing general dental treatment. Written informed consent for the IV sedation was obtained from patients or their guardian before starting the procedure. Patients or their guardians were issued a written list of presedation instructions. All patients were examined before sedation, and baseline vital signs were recorded. Vital signs were monitored during sedation, treatment, and recovery. Vital signs monitoring consisted of continuous pulse oximetry and pulse rate monitoring (INVIVO Model 4500; Invivo Research Inc, Orlando, Ra) as well as noninvasive blood pressure monitoring (Omron M4; Omron Corporation, Tokyo, Japan). This is the standard of monitoring required for patient safety and is consistent with the Policy document on sedation for dental procedures as agreed between the Royal Australasian College of Dental Surgeons and the Australian and New Zealand College of Anaesthetists. Vital signs for each patient were recorded every 5 minutes during the procedures and during recovery. Patients were most often allowed to recover in the dental chair and were usually not moved until they were ready to be discharged. A standardized written medical questionnaire (Australian Dental Association, West Australia Branch) was also used as a screening tool to identify any medical risk before treatment.
A deep sedation technique was used to sedate the patients. In order to be included in the study, the patient must have received 3 drugs administered during the sedation (fentanyl, midazolam, and propofol). Fentanyl is a short-acting opioid used to raise the patient’s pain threshold and to induce moderate sedation. Midazolam is a benzodiazepine that possesses sedative, amnestic, and muscle relaxant properties. Propofol is considered as an hypnotic in high doses but is used for its sedative and antiemetic effects in low doses. All the drugs used have very short alpha half-lives. A total of 112 patient records was examined for this study, and 86 patients met these criteria. One patient in this latter group was excluded from the study because this patient’s escort was delayed and was not available when the patient was ready for discharge; thus, this patient’s discharge time could not be reliably calculated. Eighty-five cases were therefore included in the study. After application of the monitors and application of a nasal hood attached to a nitrous oxide/oxygen apparatus delivering a minimum of 50% oxygen, an infusion of normal sterile saline or 0.45% saline and 2.5% glucose was started via a vein in the upper extremity. A 20- or 22-gauge indwelling catheter (Optiva Brand; Johnson & Johnson, Brussels, Belgium) was used in all cases. Baseline sedation was obtained using 100 |xg of fentanyl. A 25-|xg test dose was given, and after a 90-second wait, the remainder of the fentanyl was administered. After a further 2-minute wait, midazolam was then titrated (to a maximum of 5 mg) to slurring of speech as the end point of sedation. If this end point was not reached, 10-mg boluses of propofol were then administered to achieve this end point. At this point, the treating dentist was invited to administer local anesthesia. Occasionally, a 10-mg bolus of propofol was utilized to “cover” the administration of the local anesthetic. This was considered to be the start time of the procedure. Supplementary sedation, as dictated by the patients’ condition (movement, phonation, etc) or stage of procedure (vital pulp extirpation, elevation of impacted tooth, etc), was achieved by the use of 10-mg boluses of propofol as required. For cases in which procedure time was planned to go over 90 minutes, one-half the initial dose of midazolam was administered after 45 minutes.
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All data generated were entered on an Excel spreadsheet and data manipulation conducted in Microsoft Excel and Stata 5. Discharge time was calculated from the time the operating dentist indicated that he or she had finished his or her procedures to the time the patient left the surgery proper. Patients were monitored during the recovery period as for their procedure. Patients breathed 100% oxygen via a nasal hood for the first 5 minutes of recovery time. Vital signs were recorded every 5 minutes. Patients were required to achieve a score of 10 out of 10 to be discharged. A modified Aldrete postanesthetic score was used to determine the patient’s readiness for discharge. The following criteria and scoring were used:
• Patients’ vital signs (ie, blood pressure, pulse) had to be within 20% of their baseline values, oxygen saturation within 2% of preoperative values—2 points
• Patients had to be oriented as to self, place, day, and date and also had to respond appropriately to verbal questioning—2 points
• Patients had to be able to walk without assistance (where appropriate)—2 points
• Patients were required to be able to take a deep breath and cough on command—2 points
• Patients had to exhibit normal skin color and appearance—2 points
All patients’ escorts or their guardians were issued written postsedation instructions just before discharge. The postsedation instruction sheet contained an emergency contact number, should the need arise. cialis soft tabs
Blog invites submissions of review articles, reports on clinical techniques, case reports, conference summaries, and articles of opinion pertinent to the control of pain and anxiety in dentistry.