Download Sedation: A Guide to Patient Management, 5th Edition (Guide to Patient Management) PDF

TitleSedation: A Guide to Patient Management, 5th Edition (Guide to Patient Management)
Author
LanguageEnglish
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Total Pages618
Table of Contents
                            001science
002science
	Dedication
003science
004science
	Preface
		REFERENCE
005science
	About This Book
006science
	New to This Edition
007science
	Acknowlegments
008science
	Sedation in Dentistry A Historic Perspective
		REFERENCES
009science
	Pain and Anxiety in Dentistry
		BASIC FEARS
		DENTAL FEARS
		REFERENCES
010science
	SECTION II SPECTRUM OF PAIN AND ANXIETY CONTROL
		REFERENCE
011science
	Introduction to Sedation
		DEFINITIONS
		The Concept of “Rescue”
		SUMMARY
		REFERENCES
012science
	The Spectrum of Pain and Anxiety Control
		NO ANESTHESIA
		IATROSEDATION
		OTHER NONDRUG PSYCHOSEDATIVE TECHNIQUES
		ROUTES OF DRUG ADMINISTRATION
			Oral
			Rectal
			Topical
			Sublingual
			Intranasal
			Transdermal
			Subcutaneous
			Intramuscular
			Inhalation (Pulmonary)
			Intravenous
		GENERAL ANESTHESIA
		REFERENCES
013science
	Physical and Psychological Evaluation
		GOALS OF PHYSICAL AND PSYCHOLOGICAL EVALUATION
		PHYSICAL EVALUATION
			Medical History Questionnaire
			Physical Examination
				Vital Signs
				Visual Inspection of the Patient
				Additional Evaluation Procedures
			Dialogue History
		RECOGNITION OF ANXIETY
		DETERMINATION OF MEDICAL RISK
		PHYSICAL STATUS CLASSIFICATION SYSTEM
		ASA 1
		ASA 2
		ASA 3
		ASA 4
		ASA 5
		STRESS-REDUCTION PROTOCOLS
			Stress-Reduction Protocol: Normal, Healthy, but Anxious Patient (ASA 1)
			Stress-Reduction Protocol: Medical Risk Patient (ASA 2, 3, and 4)
				Recognition of Medical Risk and Anxiety
				Medical Consultation
				Premedication
				Appointment Scheduling
				Minimization of Waiting Time
				Vital Signs (Preoperative and Postoperative)
				Psychosedation During Therapy
				Adequate Pain Control During Therapy
				Duration of Treatment
				Postoperative Control of Pain and Anxiety
				Pain Control
		REFERENCES
014science
	Monitoring During Sedation
		ROUTINE PREOPERATIVE MONITORING
			Pulse (Heart Rate and Rhythm)
			Blood Pressure
			Electrocardiography
			Respiration
			Pulse Oximetry
			Carbon Dioxide Monitoring
			Bispectral Electroencephalographic Monitoring (BIS Monitoring)
			Temperature
			Other Monitoring Devices and Techniques
		RECORDKEEPING
			Sedation Record
			General Anesthesia Record
		REFERENCES
015science
	Nondrug Techniques: Iatrosedation and Hypnosis
		IATROSEDATION
			Preparatory Communication
			Euphemistic Language
				Euphemistic Language in Sedation
			Iatrosedation: Staff and Office
			Clinical Demeanor
			The Goal of Iatrosedation
		HYPNOSIS
			Hypnosis in Dentistry
			The Success of Hypnosis
			Education in Hypnosis
		SUMMARY
		REFERENCES
016science
	SECTION III ORAL, RECTAL, AND INTRAMUSCULAR SEDATION
017science
	Oral Sedation
		ADVANTAGES
		DISADVANTAGES
			Absorption
			Bioavailability
		RATIONALE FOR USE
		DRUGS
		ANTIANXIETY DRUGS
			Benzodiazepine Antianxiety Agents
				Pharmacology
				Chlordiazepoxide
				Diazepam
				Oxazepam
				Clorazepate
				Alprazolam
		SEDATIVE-HYPNOTICS
			Benzodiazepine Sedative-Hypnotics
			Benzodiazepines
				Flurazepam
				Temazepam
				Triazolam
				Lorazepam
				Midazolam
			Nonbenzodiazepine Anxiolytics-Hypnotics
				Zolpidem (Ambien)
				Zaleplon (Sonata)
				Eszopiclone (Lunesta)
			Chloral Derivatives
				Chloral Hydrate
		HISTAMINE (H1) BLOCKERS (ANTIHISTAMINES)
			Promethazine
				Contraindications
				Warnings
				Precautions
				Adverse Reactions
				Dosage
				Availability
			Hydroxyzine
				Contraindications
				Drug Interactions
				Precautions
				Dosage
				Availability
		OPIOIDS (NARCOTICS)
		THE ORAL SEDATION APPOINTMENT—Adult patient
		SUMMARY
		REFERENCES
018science
	Rectal Sedation
		ADVANTAGES
		DISADVANTAGES
		DRUGS
			Hydromorphone
				Dosage
				Availability
			Oxymorphone
				Dosage
				Availability
			Promethazine
				Dosage
				Availability
			Chloral Hydrate
				Dosage
				Availability
			Diazepam
			Midazolam
				Availability
			Ketamine
			Lytic Cocktail
		COMPLICATIONS OF RECTAL ADMINISTRATION
		SUMMARY
		REFERENCES
019science
	Sublingual, Transdermal, and Intranasal Sedation
		SUBLINGUAL SEDATION
			Nitroglycerin
			Opioids
			Oral Transmucosal Fentanyl Citrate (Fentanyl “Lollipop”)
			Sedatives
		SUMMARY (sublingual sedation)
		TRANSDERMAL SEDATION
			Opioids
			Antiemetics
		SUMMARY (transdermal sedation)
		INTRANASAL SEDATION
			Midazolam
			Sufentanil
		SUMMARY (intranasal sedation)
		REFERENCES
020science
	Intramuscular Sedation
		SUBMUCOSAL SEDATION
		SITES OF INTRAMUSCULAR DRUG ADMINISTRATION
			Gluteal Area
			Ventrogluteal Region
			Vastus Lateralis
			Deltoid
			Site Selection
		ARMAMENTARIUM
		TECHNIQUE
		COMPLICATIONS
		DETERMINATION OF DOSAGE
		DRUGS
			Antianxiety Drugs and Sedative-Hypnotics
				Chlordiazepoxide
				Diazepam
				Lorazepam
				Midazolam
			Histamine Blockers (Antihistamines)
				Promethazine
				Hydroxyzine
			Opioid Agonists
				Pharmacology
				Morphine
				Meperidine
				Meperidine With Promethazine
				Fentanyl
			Opioid Agonist-Antagonists
				Pentazocine
				Butorphanol
				Nalbuphine
			Nonsteroidal Antiinflammatory Drugs
				Ketorolac
			Dissociative Anesthetic
				Ketamine
			Anticholinergic Drugs
				Pharmacology
				Atropine
				Scopolamine
				Glycopyrrolate
			Intramuscular Sedation Techniques
			Commonly Used Intramuscular Drug Combinations
				Midazolam or Diazepam and Opioid Agonist
				Promethazine Plus Opioid
				Hydroxyzine Plus Opioid
				Meperidine, Promethazine, and Chlorpromazine
			Monitoring During Intramuscular Sedation
			The IM Sedation Appointment
		SUMMARY
		REFERENCES
021science
	SECTION IV INHALATION SEDATION
		ACKNOWLEDGMENTS
		REFERENCES
022science
	Inhalation Sedation: Historical Perspective
		BEGINNINGS (PRE-1844)
		THE EARLY DAYS (1844-1862)
		ANESTHESIA DEVELOPS (1863-1898)
		THE TWENTIETH CENTURY
		MODERN TIMES (1950-PRESENT)
			The Development of Courses and Guidelines
			The Early Anesthesia Machine
		REFERENCES
023science
	Inhalation Sedation: Rationale
		ADVANTAGES
			Disadvantages
		INDICATIONS
			Anxiety
			Medically Compromised Patients
				Cardiovascular Disease
				Respiratory Disease
				Cerebrovascular Disease
				Hepatic Disease
				Epilepsy and Seizure Disorders
				Pregnancy
				Allergy
				Diabetes
			Gagging
		CONTRAINDICATIONS
			Patients With a Compulsive Personality
			Claustrophobic Patients
			Children With Severe Behavior Problems
			Patients With Severe Personality Disorders
			Upper Respiratory Tract Infection or Other Acute Respiratory Conditions
			Chronic Obstructive Pulmonary Disease
			The Patient Who Does Not Want N2O-O2
			Pregnancy
		RESTORATIVE DENTISTRY
			Initial Dental Examination
			Removal of Provisional Crowns or Bridges
			Occlusal Adjustment
			Insertion of Matrix Bands or Wedges
		PERIODONTICS AND DENTAL HYGIENE
			Initial Periodontal Examination
			Scaling, Curettage, and Root Planing
			Emergency Management of Necrotizing Ulcerative Gingivitis
			Use of Ultrasonic Instruments
			Periodontal Surgery
		ORAL AND MAXILLOFACIAL SURGERY
			Lengthy Surgical Procedures
			Management of Abscesses
			Management of Postoperative Complications
			Suture Removal
		ENDODONTICS
			Rubber Dam Clamps
			Gaining Access to the Pulp Chamber
			Instrumenting Canals
			Filling of Root Canals
		FIXED PROSTHODONTICS
			Impression Taking
			Removal of Provisional Crowns and Bridges
			Adjustment of Castings
		REMOVABLE PROSTHODONTICS
			Preparation of Abutment Teeth
			Determination of Centric Relationships
			Occlusal Adjustments and Impression Taking
			Fitting of Immediate Dentures
		ORAL RADIOLOGY
		ORTHODONTICS
		PEDIATRIC DENTISTRY
		REFERENCES
024science
	Pharmacology, Anatomy, and Physiology
		NITROUS OXIDE
			Preparation
			Properties
				Physical Properties
				Chemical Properties
				Solubility
			Potency
			Pharmacology
			Central Nervous System
			Cardiovascular System
			Respiratory System
			Gastrointestinal Tract
			Kidneys
			Hematopoiesis
			Skeletal Muscle
			Uterus and Pregnancy
			Physiologic Contraindications
		OXYGEN
			Preparation
			Properties
			Effects of 100% Oxygen
				Central Nervous System
				Cardiovascular System
				Respiratory System
		RESPIRATORY SYSTEM
			Nose
			Mouth
			Pharynx
			Epiglottis
			Larynx
			Trachea
			Bronchi
			Bronchioles
			Alveolus
		RESPIRATION
			Mechanics of Respiration
			Composition of Respiratory Gases
		REFERENCES
025science
	Inhalation Sedation Equipment
		TYPES OF INHALATION SEDATION UNITS
			Demand-Flow Units
			Continuous-Flow Units
			Portable System
			Central Storage System
			Central Storage System With Mobile Heads
			Compressed-Gas Cylinders
			Oxygen Cylinder and Contents
			Nitrous Oxide Cylinder and Contents
			Regulators
			Manifolds (Central System Only)
			Yokes (Portable System Only)
			Flowmeters
				Flowmeter Advancements
			Emergency Air Intake Valve
			Latex-Free Accessory Equipment
				Reservoir Bag
				Conducting Tubes
				Breathing Apparatus
		SAFETY FEATURES
			Pin Index Safety System
			Diameter Index Safety System
			Minimum Oxygen Liter Flow
			Minimum Oxygen Percentage
			Oxygen Fail Safe
			Emergency Air Inlet
			Alarm
			Oxygen Flush Button
			Reservoir Bag
			Color Coding
			Lock
			Quick Connect for Positive-Pressure Oxygen
		AVAILABLE INHALATION SEDATION UNITS
		REFERENCES
026science
	Inhalation Sedation: Techniques of Administration
		GENERAL DESCRIPTION
		ADMINISTRATION
			Pretreatment Visit and Instructions
			Day of Appointment
				Monitoring During Inhalation Sedation
				Preparation of the Equipment
				Preparation of the Patient
				Technique of Administration
			Subsequent Appointments
		COMPARISON OF TECHNIQUES OF ADMINISTRATION
			Constant Liter Flow Technique
				Summary of Technique
				Advantages
				Disadvantage
				Examples of Technique
			Constant O2 Flow Technique
				Summary of Technique
				Advantages
				Disadvantages
				Examples of Technique
		NORMAL DISTRIBUTION CURVE
		TITRATION AND TIME
		SIGNS AND SYMPTOMS OF OVERSEDATION
			Clinical Indicators of Oversedation
				The Patient Persistently Closes the Mouth
				The Patient Spontaneously Begins Mouth Breathing
				The Patient Complains of Nausea and Effects of Sedation Felt as Too Intense or Uncomfortable
				The Patient Fails to Respond Rationally or Gives Sluggish Responses
				The Patient Begins to Lose Control
				The Patient Speaks Incoherently or Dreams
				The Patient Becomes Uncooperative
				The Patient Laughs, Cries, or Becomes Giddy
				The Patient Has Uncoordinated Movements
		REFERENCES
027science
	Inhalation Sedation: Complications
		INADEQUATE OR INCOMPLETE SEDATION
		POOR PATIENT EXPERIENCE
		EQUIPMENT PERFORMANCE
		POTENTIAL COMPLICATIONS
			Nausea and Vomiting
				Presence of Food in the Stomach
				Oversedation
				The “Roller Coaster Ride”
				Length of Sedation
				Prior History of Nausea and Vomiting
				Patient Positioning
				Management of Vomiting
			Tooth Pain Associated With Sinus Pressure
			Vertigo
			Bowel Discomfort
			Claustrophobia
			Contact Lens Wearers
			Anatomic Obstruction
			Understanding of the Language
			Esoteric Potential Complications
		MANAGING COMPLICATIONS
		REFERENCES
028science
	Contemporary Issues Surrounding Nitrous Oxide
		POTENTIAL BIOHAZARDS FROM LONG-TERM EXPOSURE TO TRACE ANESTHETIC GAS
			Scavenging
			Monitoring of Trace Nitrous Oxide
				Bacharach Monitor
		RECREATIONAL ABUSE OF NITROUS OXIDE
		SEXUAL AWARENESS REGARDING NITROUS OXIDE
		REFERENCES
029science
	Practical Considerations
		DETERMINATION OF PROPER TITRATION AT SUBSEQUENT VISITS
			Procedural Anxiety
			Baseline Level of Stress
			Level of Fatigue
		POOR PATIENT EVALUATION
		PATIENT UNATTENDED DURING SEDATION
		IMPROPER RECOVERY PROCEDURES
		POSTSEDATION NAUSEA, HEADACHE, AND LETHARGY
		WHO ADMINISTERS NITROUS OXIDE?
		EQUIPMENT
		REFERENCES
030science
	Teaching Inhalation Sedation: History and Present Guidelines
		GENERAL PRINCIPLES OF Minimal SEDATION
			Education Courses
			Teaching Administration of Minimal Sedation
			General Objectives
		INHALATION SEDATION (NITROUS OXIDE-OXYGEN)
			Inhalation Sedation Course Objectives
			Inhalation Sedation Course Content
			Inhalation Sedation Course Duration
			Participant Evaluation and Documentation of Inhalation Sedation Instruction
			Faculty
			Facilities
		REFERENCES
031science
	SECTION V INTRAVENOUS SEDATION
		REFERENCES
032science
	Intravenous Sedation: Historical Perspective
		THE EARLY DAYS
		THE 1800s
		THE 1900s
		REFERENCES
033science
	Intravenous Moderate Sedation: Rationale
		ADVANTAGES
		DISADVANTAGES
		CONTRAINDICATIONS
		INDICATIONS
			Anxiety
			Amnesia
			Medically Compromised Patients
				Previous Cerebrovascular Accident
				Epilepsy
			Control of Secretions
			Analgesia
			Diminished Gagging
		REFERENCES
034science
	Armamentarium
		INTRAVENOUS DRUG ADMINISTRATION
			Direct Intravenous Administration
			Needle Maintained in the Vein Without Continuous Infusion
			Continuous Intravenous Infusion
		ADVANTAGES AND DISADVANTAGES OF VARIOUS METHODS
		INTRAVENOUS INFUSION SOLUTION
			Choice of Solution
			Volume of Solution
		INTRAVENOUS ADMINISTRATION SET
		NEEDLES
			Gauge
			Types
		OTHER ITEMS
		REFERENCES
035science
	Anatomy for Venipuncture
		ARTERIES OF THE UPPER LIMB
		VEINS OF THE UPPER LIMB
		ANATOMY
			Dorsum of the Hand
			Wrist
			Forearm
			Antecubital Fossa
			Foot
		SELECTION OF VENIPUNCTURE SITE
			Condition of the Superficial Veins
			Relationship of the Vein to Other Anatomic Structures
			Duration of the Venipuncture
			Clinical Status of the Patient
			Age (Size) of the Patient
			Type of Intravenous Procedure
		RECOMMENDED SITES FOR VENIPUNCTURE
		REFERENCES
036science
	Venipuncture Technique
		PREPARATION OF EQUIPMENT
		PREPARATION FOR VENIPUNCTURE
		INDWELLING CATHETER
		WINGED INFUSION SET
			Basic Technique—Winged Infusion Set
		HOLLOW METAL NEEDLE
			Basic Technique—Hollow Metal Needle
		VENIPUNCTURE TECHNIQUE
			Dorsum of Hand
			Dorsum of Wrist
			Ventral Forearm
			Antecubital Fossa
		TERMINATING THE INTRAVENOUS INFUSION
		REFERENCES
037science
	Pharmacology
		BENZODIAZEPINES
			Diazepam
				Chemistry
				General Pharmacology
				Fate of Intravenous Diazepam
				Biotransformation
				Effects of Age and Disease
				Skeletal Muscle Relaxation
				Anticonvulsant Activity
				Cardiovascular System
				Respiratory System
				Hepatic Disease
				Pain
				Amnesia
				Contraindications
				Warnings
				Use in Pregnancy
				Pediatric Use
				Precautions
				Adverse Reactions
				Dosage
				Availability
			Midazolam
				Pharmacokinetics and Biotransformation
				Amnesia
				Duration of Clinical Activity
				Cardiorespiratory Activity
				Side Effects
				Dosage and Administration
				Availability
			Lorazepam
				Warnings and Precautions
				Pediatric Use
				Adverse Reactions
				Dosage
				Administration
				Availability
			Flunitrazepam
				Side Effects and Complications
				Flunitrazepam Sedation in Dentistry
				Availability
			Chlordiazepoxide
		SUMMARY
		BARBITURATES
		SUMMARY
		HISTAMINE BLOCKERS (ANTIHISTAMINICS)
			Promethazine
				Dosage
				Availability
		SUMMARY
		PROPOFOL
			Pharmacodynamics
				Central Nervous System
				Respiratory System
				Cardiovascular System
			Miscellaneous Effects
				Clinical Use
				Warnings
				Adverse Reactions
				Dosage and Administration
				Sedation
			Availability
		OPIOID ANALGESICS
		OPIOID AGONISTS
			Meperidine
				Dosage
				Availability
			Morphine
				Dosage
				Availability
			Fentanyl
				Indications
				Contraindications
				Warnings
				Precautions
				Adverse Reactions
				Dosage
				Availability
			Alfentanil, Sufentanil, and Remifentanil
				Availability
		OPIOID AGONIST-ANTAGONISTS
			Pentazocine
				Contraindications
				Warnings
				Precautions
				Adverse Reactions
				Dosage
				Availability
			Nalbuphine
				Pharmacology
				Pharmacokinetics
				Adverse Effects
				Overdose
				Contraindications
				Warnings
				Precautions
				Dosage
				Availability
			Butorphanol
				Pharmacology
				Pharmacokinetics
				Effect on Respiration
				Cardiovascular Effects
				Side Effects
				Overdose
				Warnings
				Precautions
				Dosage
				Availability
		SUMMARY
		OPIOID ANTAGONISTS
		ANTICHOLINERGICS
			Pharmacology
			Mechanism of Action
			Central Nervous System
			Eye
			Respiratory Tract
			Cardiovascular Actions
			Gastrointestinal Tract
			Secretory Glands
			Biotransformation
			Atropine
				Adverse Reactions
				Dosage
				Availability
			Scopolamine Hydrobromide
				Dosage
				Availability
			Glycopyrrolate
				Warnings
				Precautions
				Dosage
				Availability
		SUMMARY
		KETAMINE
		ANTIDOTAL DRUGS
			Opioid Antagonists
				Naloxone
		SUMMARY
			Benzodiazepine Antagonist
				Dosage
				Availability
			Reversal of Emergence Delirium
				Physostigmine
		SUMMARY
			Vasodilator for Extravascular or Intraarterial Drug Administration
				Procaine
		REFERENCES
038science
	Intravenous Moderate Sedation: Techniques of Administration
		MONITORING DURING INTRAVENOUS SEDATION
		BASIC INTRAVENOUS MODERATE SEDATION TECHNIQUES
			Midazolam or Diazepam?
			Intravenous Benzodiazepine (Midazolam or Diazepam)
				Preliminary Appointment
				Day of Treatment
				Midazolam
				Diazepam
			Retitration of Midazolam or Diazepam
		SUMMARY
		MODIFICATIONS OF BASIC TECHNIQUES
			Anticholinergic + Benzodiazepine
				Technique
			Opioid + Benzodiazepine
				Rationale for Advanced Techniques
				Requirement: Sedation
				Requirement: Analgesia
				Techniques
		OTHER TECHNIQUES— A BRIEF REVIEW
			The Jorgensen Technique—an Overview
				Function of the Individual Drugs
			Diazepam With Methohexital (Foreman Technique)
			The Berns Technique
			The Shane Technique
			Propofol
		SUMMARY
		REFERENCES
039science
	Intravenous Sedation: Complications
		VENIPUNCTURE COMPLICATIONS
			Nonrunning Intravenous Infusion
				IV Infusion Bag Too Close to the Heart Level
				Bevel of Needle Against Wall of Vein
				Tourniquet Left on Arm
				Infiltration
			Venospasm
				Prevention
				Recognition
				Management
			Hematoma
				Prevention
				Recognition
				Management
			Infiltration
				Prevention
				Cause
				Recognition
				Management
			Localized Venous Complications
			Air Embolism
				Management
			Overhydration
		LOCAL COMPLICATIONS OF DRUG ADMINISTRATION
			Extravascular Drug Administration
				Causes
				Recognition
			Intraarterial Injection
				Prevention
				Recognition
				Management
			Local Venous Complications
				Prevention
				Recognition
				Management
		GENERAL DRUG-RELATED COMPLICATIONS
			Nausea and Vomiting
				Causes of Nausea and Vomiting
				Management of Nausea
				Management of Vomiting
			Localized Allergy
			Respiratory Depression
				Recognition
				Management
			Emergence Delirium
				Prevention
				Management
			Laryngospasm
				Recognition
				Management
		SPECIFIC DRUG COMPLICATIONS
			Benzodiazepines
			Promethazine
			Opioids
			Scopolamine
		SUMMARY
		REFERENCES
040science
	Practical Considerations
		REFERENCES
041science
	Guidelines for Teaching
		REFERENCES
042science
	SECTION VI GENERAL ANESTHESIA
		REFERENCEs
043science
	Fundamentals of General Anesthesia
		ADVANTAGES
		DISADVANTAGES
		CONTRAINDICATIONS
		INDICATIONS
		TYPES OF GENERAL ANESTHESIA
			Outpatient General Anesthesia
				Intravenous Propofol or Barbiturates
				Conventional Operating Room Type of General Anesthesia in an Outpatient Environment
			Inpatient General Anesthesia
		EDUCATION IN GENERAL ANESTHESIA
			Guidelines Relative to the Establishment of a Dental Residency in Anesthesiology
		ACCREDITED ANESTHESIOLOGY RESIDENCIES IN WHICH DENTISTS CAN ENROLL
		REFERENCES
044science
	Armamentarium, Drugs, and Techniques
		ARMAMENTARIUM
			Anesthesia Machine
			Intravenous Equipment
			Ancillary Anesthesia Equipment
				Face Masks
				Laryngoscopes
				Endotracheal Tubes and Connectors
				Laryngeal Mask Airway (LMA)
				Oropharyngeal and Nasopharyngeal Airways
				Tonsillar Suction Tips
				Magill Intubation Forceps
				Sphygmomanometers and Stethoscopes
			Monitoring Equipment
			Emergency Equipment and Drugs
		DRUGS
			Intravenous Induction Agents
				Barbiturates
				Benzodiazepines
				Other Agents
			Opioids
			Neuroleptanalgesia-Neuroleptanesthesia
			Dissociative Anesthesia
			Muscle Relaxants (Neuromuscular Blocking Drugs)
			Inhalation Anesthetics
		TECHNIQUES
			Inpatient General Anesthesia
			Ambulatory General Anesthesia
				Conventional General Anesthetics
				Intravenous General Anesthesia
		SUMMARY
		REFERENCES
045science
	SECTION VII EMERGENCY PREPARATION AND MANAGEMENT
		REFERENCES
046science
	Preparation for Emergencies
		OFFICE
		OFFICE PERSONNEL
			Basic Life Support
			Advanced Cardiovascular Life Support
			Pediatric Advanced Life Support
			Team Approach to Emergency Management
		EMERGENCY PRACTICE DRILLS
			The Institute of Medical Emergency Preparedness (IMEP)*
		OUTSIDE MEDICAL ASSISTANCE
		SUMMARY
		REFERENCES
047science
	Emergency Drugs and Equipment
		LEVEL 1: BASIC EMERGENCY KIT
			Injectable Drugs
			Noninjectable Drugs
			Primary (Basic) Emergency Equipment
		LEVEL 2: SECONDARY (NONCRITICAL) DRUGS AND EQUIPMENT
			Injectable Drugs
			Noninjectable Drugs
			Secondary (Advanced) Emergency Equipment
		LEVEL 3: ADVANCED CARDIAC LIFE SUPPORT
		LEVEL 4: ANTIDOTAL DRUGS
		SUMMARY
		REFERENCES
048science
	Management of Emergencies
		OVERDOSE
			Predisposing Factors and Prevention
			Clinical Manifestations
				Sedative-Hypnotics, Including Barbiturates
				Opioid Agonists
			Management
				Sedative-Hypnotic Drugs
			Opioid Analgesics
		SUMMARY
		ALLERGY
			Prevention of Allergic Reactions
			Clinical Manifestations
			Onset
				Skin Reaction
				Respiratory Reactions
				Generalized Anaphylaxis
			Management
				Skin Reactions
				Respiratory Reactions
				Generalized Anaphylaxis
			Signs of Allergy Present
			No Signs of Allergy Present
		HYPOTENSION
			Causes of Hypotension
			Management of Hypotension
			Hypotension in Patients Receiving Corticosteroid Therapy
			Hypotension in Patients Receiving β-Blockers
		HYPERTENSIVE EPISODES
			Management of a Hypertensive Crisis
		CARDIAC DYSRHYTHMIAS
			Precipitating Factors
		ANGINA PECTORIS
			Signs and Symptoms
		MYOCARDIAL INFARCTION
			Signs and Symptoms
			Management
		AIRWAY OBSTRUCTION
			Management
				Partial Airway Obstruction Associated with “Snoring”
				Partial Airway Obstruction Associated With “Gurgling”
				Partial Airway Obstruction Associated With “Wheezing”
				Cricothyrotomy
		LARYNGOSPASM
			Management
		EMESIS AND ASPIRATION OF FOREIGN MATERIAL UNDER ANESTHESIA
			Management
		HYPERVENTILATION
			Management
		RESPIRATORY DEPRESSION
			Management
		SEIZURES
			Management
		HYPOGLYCEMIA
			Management
		SYNCOPE
			Management
		SUMMARY
		REFERENCES
049science
	SECTION VIII SPECIAL CONSIDERATIONS
		REFERENCEs
050science
	The Pediatric Patient
		FACTORS INFLUENCING PATIENT RESPONSE
		BEHAVIORAL EVALUATION OF THE PEDIATRIC PATIENT
		DETERMINING THE NEED FOR SEDATION
		GOALS AND TECHNIQUES
		MONITORING
		PHYSICAL RESTRAINT
		MOUTH-STABILIZING DEVICES
		DRUGS
			General Rules for Preoperative Medication
			Oral Sedation
				Chloral Hydrate
				Hydroxyzine
				Promethazine
				Midazolam
				Diazepam
			Oral Combinations
				Chloral Hydrate Plus Promethazine
				Promethazine Plus Meperidine
			Parenteral Sedation
				Meperidine Plus Promethazine
				Lytic Cocktail
				Midazolam
				Ketamine
			Inhalation Sedation
				Dosage
			Nitrous Oxide-Oxygen With Other Techniques
			Intravenous Sedation
		DISCHARGE FROM THE OFFICE
		RECORDKEEPING
		GENERAL ANESTHESIA
		REFERENCES
051science
	The Geriatric Patient*
		COMMON HEALTH PROBLEMS
			Arthritis
			Hypertension
			Heart Disease
			Emphysema
			Glaucoma
		MANAGEMENT OF PAIN AND ANXIETY
		REFERENCES
052science
	The Medically Compromised Patient
		CARDIOVASCULAR DISEASE
			Angina Pectoris
			Unstable Angina
			Myocardial Infarction
			High Blood Pressure
			Dysrhythmias
			Heart Failure
			Congenital Heart Disease
			Valvular Heart Disease
		RENAL DISEASE
		RESPIRATORY DISEASE
			Asthma
			Chronic Obstructive Pulmonary Disease
			Emphysema
			Chronic Bronchitis
		NEUROLOGIC DISORDERS
			Seizure Disorders
			Cerebrovascular Accident
			Myasthenia Gravis
		LIVER DISEASE
		ENDOCRINE DISORDERS
			Thyroid Gland Dysfunction
			Hyperthyroidism
			Hypothyroidism
			Adrenal Disorders
		METABOLIC AND GENETIC DISORDERS
			Diabetes Mellitus
			Porphyria
			Malignant Hyperthermia
			Atypical Plasma Cholinesterase
		HEMATOLOGIC DISORDERS
			Anemia
			Sickle Cell Anemia
			Polycythemia Vera
			Hemophilia
		REFERENCES
053science
	The Physically Compromised Patient
		MULTIPLE SCLEROSIS
			Environmental
			Genetic
			Immunologic
			Viral
		MUSCULAR DYSTROPHY
		PARKINSON DISEASE
		CEREBROVASCULAR ACCIDENT (CVA, STROKE, CEREBRAL ACCIDENT, “BRAIN ATTACK”)
		REFERENCES
054science
	Neurologic Illnesses and Other Conditions
		ALZHEIMER DISEASE
		AUTISM
		CEREBRAL PALSY
		DOWN SYNDROME
		INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
		SCHIZOPHRENIA
		REFERENCES
055science
	Medicolegal Considerations
		THE UNIQUE STATUS OF SEDATION IN DENTISTRY
		LEGAL HISTORY
		MODERN LIABILITY INSURANCE CRISES
		LIABILITY INSURANCE COVERAGE
		THEORIES OF LIABILITY
			Statute Violation
			Contract Law
			Criminal Law
			Tort Law
			Duty
			Breach of Duty
			Causation
			Damage
			Reasonableness
			Consent
			Statute of Limitations
		EMERGENCIES DURING SEDATION
			Consent During Emergencies
			Defining Emergency
			Defining Sedation Emergencies
		EMERGENCY RESCUES—GOOD SAMARITAN STATUTES
		RELATIONSHIP BETWEEN DENTIST AND EMERGENCY PATIENT
			Foreseeability
		LIMITING LIABILITY FOR EMERGENCIES
			Prevention and Preparation
			Poor Decisions
			Respondeat Superior
			Community Standards
			Professional Relationships
			Collegiality
		PHILOSOPHICAL ASPECTS OF TREATING EMERGENCIES
		REFERENCES
056science
	The Controversial Development of Anesthesiology in Dentistry
		HORACE WELLS AND WILLIAM T.G. MORTON
		EARLY RESISTANCE TO ANESTHESIA
		PROFESSIONAL LITERATURE, THE DENTAL COSMOS
		VARIED ANESTHESIA PROVIDERS
		AMERICAN SOCIETY OF EXODONTISTS
		ORAL AND MAXILLOFACIAL SURGERY ANESTHESIA PIONEERS
		AMERICAN DENTAL SOCIETY OF ANESTHESIOLOGY
		HISTORICAL DENTAL ANESTHESIOLOGY TRAINING
		AMERICAN SOCIETY OF DENTIST ANESTHESIOLOGISTS
		AMERICAN SOCIETY OF ORAL AND MAXILLOFACIAL SURGEONS
		OFFICE ANESTHESIA EVALUATIONS
		MEDICAL ANESTHESIA’S STATUS IN OFFICE-BASED ANESTHESIOLOGY
		EXTRAPROFESSIONAL CRITICISM OF DENTAL ANESTHESIOLOGY
		AAOMS RESPONSES
		POSWILLO REPORT AND ALASKA
		1990S DENTAL ANESTHESIOLOGY SPECIALTY APPLICATIONS
		NEED AND DEMAND
		ORAL SEDATION ENTREPRENEURIAL GROUPS
		FROM THE SOCIETIES, STATES, CONGRESS, AND THE UNITED STATES SUPREME COURT
		COMPETING DENTAL FACTIONS
		FUTURE OF DENTAL ANESTHESIOLOGY
		REFERENCES
057science
	Guidelines for the Use of Parenteral Sedation: University of Southern California School of Dentistry
058science
	Index
		A
		B
		C
		D
		E
		F
		G
		H
		I
		J
		K
		L
		M
		N
		O
		P
		Q
		R
		S
		T
		U
		V
		W
		Y
		Z
                        
Document Text Contents
Page 1

11830 Westline Industrial Drive
St. Louis, Missouri 63146

SEDATION: A CLINICAL GUIDE TO PATIENT MANAGEMENT ISBN: 978-0-323-05680-9
Copyright © 2010, 2003, 1995, 1989, 1985 by Mosby, Inc., an affiliate of Elsevier Inc.

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval
system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s
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e-mail: [email protected] You may also complete your request on-line via the Elsevier website
at http://www.elsevier.com/permissions.

Library of Congress Cataloging-in-Publication Data or Control Number
Malamed, Stanley F., 1944-
Sedation : a guide to patient management / Stanley F. Malamed.—5th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-323-05680-9 (pbk. : alk. paper) 1. Sedatives. 2. Anesthesia in dentistry. I. Title.
[DNLM: 1. Anesthesia, Dental—methods. 2. Conscious Sedation. 3. Deep Sedation. 4. Dental
Anxiety—prevention & control. 5. Pain—prevention & control. WO 460 M236s 2010]
RK512.S44M35 2010
615′.782—dc22

2009001828

Vice President and Publishing Director: Linda Duncan
Executive Editor: John Dolan
Developmental Editor: Brian S. Loehr
Publishing Services Manager: Catherine Jackson
Senior Project Manager: Rachel E. McMullen
Design Direction: Jessica Williams

Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Notice

Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our knowledge, changes in practice, treatment, and drug therapy may become necessary or
appropriate. Readers are advised to check the most current information provided (i) on procedures
featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose
or formula, the method and duration of administration, and contraindications. It is the responsibility of
the practitioner, relying on their own experience and knowledge of the patient, to make diagnoses, to
determine dosages and the best treatment for each individual patient, and to take all appropriate safety
precautions. To the fullest extent of the law, neither the Publisher nor the Author assumes any liability for
any injury and/or damage to persons or property arising out of or related to any use of the material
contained in this book.

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Page 2

Chapter 1 Emergency Preparation and Management �



To Francis Foldes, MD, for having instilled in me an everlasting fascination in the art
and science of anesthesiology, and to Norman Trieger, DMD, MD and Thomas
Pallasch, DDS, MS, for having made possible a career that has provided me with
continued challenge, interest, and enjoyment, one that I would change for no other, and
to Horace Wells, DDS, who 165 years ago discovered anesthesia.

Dedication

Horace Wells (1815-1848) (Courtesy the
Horace Wells Museum, Hartford, Conn.)

Page 309

CHAPTER 23 Anatomy for Venipuncture 299

simplify the problem of restraint of the infant. In seriously ill
newborn infants, the umbilical vein may be used during the
first 24 to 48 hours of life.

Smaller children, because their limbs are “pudgier,” may
have superficial veins of the upper limb that are quite difficult
to visualize. The foot may prove a more acceptable site for
venipuncture.

In very obese adult patients, veins may prove difficult or
impossible to locate. A careful search of both arms and if
necessary the feet will usually be fruitful in locating one or
more veins. If the planned dental procedure is elective, the
absence of superficial veins should be considered a contrain-
dication to the use of IV sedation. Should it be essential to
establish an IV line, hospitalization of the patient, with sub-
sequent surgical cutdown to cannulate a vein, may be the
most prudent course of action.

Type of Intravenous Procedure
The chemical nature of the drugs administered, the size of the
vein to be cannulated, and the size of the needle are important
because they all may produce irritation of the inner wall of
the vein, a situation leading to an increased risk of
phlebitis.

In general, the larger the vein is in relation to the size of
the needle or catheter, the less likelihood there is that irrita-
tion and phlebitis will develop. This is because the drugs and
infusion solution will undergo more rapid dilution in the
blood where the caliber of the vein exceeds the outside diam-
eter of the needle or cannula. Mechanical irritation by the
needle or cannula against the endothelial wall of the vein is
another cause of phlebitis. Cannulation of larger veins is a
means of decreasing risk of venous irritation and subsequent
phlebitis.

Two drugs discussed in this section are capable of produc-
ing significant venous irritation. These drugs, diazepam (fre-
quently used) and pentobarbital (rarely used), are used
intravenously as sedatives in dentistry and medicine. Methods
of minimizing the risk of phlebitis when these drugs are
administered are discussed in Chapter 26. These drugs should
be administered slowly into a rapidly running IV infusion. In
addition, the use of larger veins will minimize but not elimi-
nate the risk of developing venous irritation.

RECOMMENDED SITES
FOR VENIPUNCTURE
Five potential sites for venipuncture in the upper limb have
been reviewed in this chapter. They are, in my order of prefer-
ence (Figure 23-7), as follows:

1. Dorsum of hand
2. Ventral forearm
3. Lateral antecubital fossa
4. Dorsal wrist
5. Medial antecubital fossa

The dorsum of the hand remains the most preferred site
because its veins are superficial and because of the anatomic
safety of the site. However, the dorsum is not always an
appropriate site for drugs that may produce venous irritation
(e.g., diazepam). A close second on my list is the ventral
forearm. This site is preferred for longer-duration procedures
and when the dorsum of the hand is not available. The
absence of a need for immobilization of a joint, anatomic
safety, and larger veins make this site suitable for most veni-
puncture procedures. A third preferred site, the lateral
antecubital fossa, is chosen for its larger veins and anatomic
safety.

Figure 23-7 Sites of venipuncture in order of preference: 1, dorsum of
hand; 2, ventral forearm; 3, lateral antecubital fossa; 4, dorsal wrist; and
5, medial antecubital fossa. (Adapted from Abbott Laboratories: Venipunc-
ture and venous circulation, Chicago, 1971, Abbott Laboratories.)

1

4

5

3

2

Page 310

300 CHAPTER 23 Anatomy for Venipuncture

Figure 23-8 Blood circulation in the upper extremity. Blood leaves the left ventricle; traverses arteries, arterioles, capillaries, venules, and veins and returns
to the right atrium via the superior vena cava.

Left ventricle

Ascending aorta

Aortic arch

Subclavian (brachiocephalic
[innominate] on right)

Brachial

Superficial and deep
volar arches

Axillary

RadialUlnar

Digital arteries

Capillaries

Arterioles

ARTERIAL SUPPLY

Capillaries

Venules

Dorsal venous network

Axillary

Median

Brachial

Axillary

Subclavian

Brachiocephalic
(innominate)

Superior vena cava

Right atrium of heart

Superficial and deep volar arches

Brachial

RadialUlnar

BasilicCephalic

Median basilicMedian cephalic

Deep veinsSuperficial veins

VENOUS RETURN

Page 617

Index 607

Tingling, during sedation, 236–237
Tinnitus, 32
Titration

definition of, 17
drug administration, method of, 17t
in geriatric patient, 518
importance of, 228
of orally administered drugs, 16–17
for subsequent sedation appointments,

260–261
Titration by appointment, 498–499
Tobacco

current use of, 45
Tonic-clonic seizure, generalized, 531

epilepsy and, 486
management of, 487b

Tonsillar suction tip, 418–419
Tonsils, inhalation sedation and, 251
Tooth pain, 251
Topical anesthesia, 11, 18
Topical application of drug, 18
Tort law, 561–562
Total intravenous anesthesia (TIVA)

equipment for, 413
inhalation sedation unit for, 414

Tourniquet, 289, 289f
application of, 306f
forgotten, 378

Toxic reaction, 455
Trace nitrous oxide

air sweeps and, 254
monitoring of, 254–257

Trachea, 197f
respiratory system, role in, 198

Tracheal intubation
dysrhythmia and, 479

Tracking, of vein, 331, 331f
Traditional nasal hood, 218f
Tranquilizer, major, 113
Transdermal drug administration, 18

advantages of, 126–127
Transdermal sedation

indication and types of, 126–127
Transdermal therapeutic system (TTS),

126
advantages of, 126
phamacokinetics of, 127

Transfusion, blood, 44
Transient ischemic attack (TIA), 549–550
Translocation DS, 554
Traumatic procedure

anesthesia as, 10
general anesthesia for, 408

Trendelenburg position, 484
Triazolam

dental drug interactions with, 38t–43t
oral administration of, 107–108
overview of, 108b

Tricyclic antidepressant
dental drug interactions with, 38t–43t
intravenous sedation and, 277

Trieger test, 228–229, 241f, 305
Trimethoprim

dental drug interactions with, 38t–43t
Trisomy 21, 554
Tuberculosis, 35
Tubocurarine, 425
Tumor, 36
Twilight sleep, 10
Type 1, insulin-dependent diabetes mellitus

(IDDM), 488, 539–540
Type 2, non-insulin-dependent diabetes

mellitus (NIDDM), 488, 539–540

U
Ulcer, 35
Ulnar artery, 293
Ultralight general anesthesia, 168, 403,

408–409
Unconscious patient

BIS values in, 76
management of, 21
from overdose, 459, 459f

Uncooperativeness, oversedation and, 247
Uncoordination, oversedation and, 247
Uneasiness, in patient, 4
Unknown, fear of, 4
Unstable angina, 521–522

as ASA 4 patient, 521–522
mortality rate of, 521
oral sedation and, 522
pain in, 521
See also Angina pectoris

Upper respiratory infection
inhalation sedation and, 185

Urinary problems, 32
Urinary tract

anticholinergic effect on, 155
Urine output, collection and measurement of,

421
Urticaria, 467

V
Vagal response

dysrhythmia and, 479
Valium, 103, 322
Valproic acid

dental drug interactions with, 38t–43t
epilepsy and, 532t

Valvular heart disease, 527
Van Horn v. Watson, 566–567
Vaporizer, 413
Vaporole, 449–450, 450f
Vascular system

diabetes mellitus and, 540t
Vasoconstrictor

contraindications for, 525b
dental drug interactions with, 38t–43t
in geriatric patient, 517

Vasodepressor
hypotension and, 475

Vasodepressor syncope, 471
Vasodilation

methods of, 306
nitrous oxide-oxygen as, 306

Vasodilator, 290f
for emergency kit, 446, 452

Vasopressor
cerebrovascular accident and, 533
heart failure and, 526
hyperthyroidism and, 536–537
indication for, 449
receptor, action on, 476t
valvular replacement and, 527

Vasopressor syncope. See Syncope
Vastus lateralis, for IM drug administration,

135–136, 135f–136f
Vecuronium, 425
Vein

distention of, 306f
tracking of, 331, 331f
of upper limb, 294

Vein locating device, 307f
Venereal disease, 36
Venipuncture

blood return, 312, 312f
complications from, 384–386

air embolism, 381
cause of, 381
drug related, 377b, 386–392
IV infusion bag level, 376–377
needle placement, 378f
nonrunning IV infusion, 376–381
overhydration, 381
prevention of, 385
tourniquet and, 378f

with continuous infusion, 281, 281f
equipment for, 280, 414
equipment preparation for, 302–304, 303f
in geriatric patient, 517–518
hematoma from, 379–380
infiltration and, 378–379
nitrous oxide-oxygen as aid for, 306
patient cooperation for, 20, 275
patient preparation for, 304–308
proficiency in, 396
qualification for administering, 395
recognition and management of, 385–386
site selection for, 299f

comparison of, 301t
factors involving, 298–299

technique for
antecubital fossa, 313–314
hand, dorsum of, 311–312
ventral forearm, 313, 314f
wrist, dorsum of, 312, 313f

terminating infusion, 315, 315f
tourniquet application for, 306f
upper limb

arteries of, 292–294
veins of, 294

venous distention for, 306, 306f
without continuous infusion, 280, 281f
See also Intravenous drug administration
See also Venospasm

Venospasm
indication of, 379
recognition and management of, 379

Ventilation
assisted/controlled, 389f
controlled, 446–447
monitoring guidelines for, 65b–66b
sedation and, 11

Ventral forearm. See Forearm
Ventricular defibrillation, 51
Ventricular septal defect, 526
Ventrogluteal region, for IM drug

administration, 135, 135f
Verrill, P.J., 273
Verrill sign, 273, 317, 318f
Vertigo, 251
Viral hepatitis, 534
Viral infection, 31
Virus

multiple sclerosis and, 547
Vision, blurred, 32
Visual inspection, of patient, 53–54
Vital signs

on anesthesia record, 429f
baseline, 67f
difficulties in monitoring, 78–79
during IV sedation, 355–356
monitor for, 70f, 75f
monitoring guidelines for

adults, 68t
children, 69t

in pediatric patient, 500
preoperative and postoperative, 60
preoperative chart for, 359f

Venipuncture (Continued)

Page 618

608 Index

sedation and, 50, 64
types of, 47–53

Vocal cord
laryngospasm and, 391
view of, 391f

Vomiting, 31
under anesthesia

incidence of, 484
management of, 484
pediatric patient and, 507–508

cause of, 386–387
from inhalation sedation, 249–251
management of, 250–251, 250f, 387
opioid agonist and morphine, effect on, 147
signs and symptoms of, 250

Von Liebig, 166
von Mering, J., 272
Vulnerability

death, fear of, 4–5
patient position and, 4

W
Waiting time, minimization of, 60
Waiver, to consent, 563

Waldie, David, 171
Walters, John, 561
Warmth, during sedation, 228–229
Washington, James Augustus, 272
Water vapor

composition of, 200
Weight

guidelines for, 53, 53f
technique for, 53

Weight loss, 31
Wells, Dr. Horace, 166–167, 168f, 170f, 265,

573–574, 573f
Wheals, 467
Wheezing, 72–73, 73t

airway obstruction and, 481
as allergic reaction, 467
management of, 481t
partial airway obstruction and, 483

Whipped cream, 257–258, 257f
Whippet, 257–258
White-knuckle syndrome, 228–229, 238f
Whooshing, 72

management of, 481t
Winged infusion set, 310
Winged needle, 286, 287f, 310f

Woo v. Foreman’s Fund Insurance Co., 560
Wren, Sir Christopher, 272
Wright’s classification, 497
Wrist

dorsum of, 295–296, 295f, 312, 313f
Writ of certiorari, 580f
Wyckoff, B.S., 272–273

Y
Yellow fever board, 563
Yoke, 212–213
Young’s rule

for IM drug administration, 140
for pediatric drug dosages, 499

Z
Zaleplon (Sonata)

dental drug interactions with, 38t–43t
oral administration of, 109–111
overview of, 110b

Zerfas, L.G., 272
Zolpidem (Ambien)

dental drug interactions with, 38t–43t
oral administration of, 109–110
overview of, 110b

Vital signs (Continued)

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