Medication, usually Midazolam or Propofol, that is administered intravenously is administered through the veins. Because of its rapid and predictable effects in many cases in can be an first option of choice.
- Midazolam is class 3 registered drug
- Faster onset of the sedation medications, meaning patient is able to feel the effects of the medication immediatelly
- Designed to relax eg. highly-anxious and nervous patients and makes patient completely comfortable by efficient elimination anxiety and fear.
- Patient will not be asleep during your appointment and will still be able to respond to verbal cues
- Patient will be unaware of the sights, smells and sounds of the dental office
- Patients remember little-to-nothing of their appointment, amnesia effect
- Gives an optimal control of the amount of medication administered and allows them to readily increase or decrease your level of sedation as needed, quickly and comfortably.
- Patient may benefit from IV sedation if he/she has a sensitive gag reflex or difficulty sitting in a dental chair for long periods of time
- Limitations of IV sedation may include: severe medical conditions, pregnancy, allergic reactions to certain medications, complex health issues
- Good practice to use oral premedication or transmucosal sedation before cannulation.
- midazolam box should be present with untampered seal
- be carefull re: sometimes similar boxes colours for midazolam and flumazenil (eg. white and red colours). Good practice to use totally boxes which are easy to distinguish, eg. Anexate vs Midazolam box
- reflective practice through use of log book
- supervised clinical practice
- non-fasting makes patient more comfortable
- those not fasting for sedation need to be able to justify their position
- IV sedation with midazolam works very well and effective in adolescent orthodontic patients who require ortho extractions
- Hard to manage IV procedure for young adolescents just above 12 y.o. Better to start with 16 y.o. and develop experience providing IV for younger patients (decreasing age)
- no evidence based for the routine use of capnography monitoring during IV sedation, however can be considered for ASA III-IV patients
- standard monitoring: oxygen saturation, BP and pulse
- if O2 saturation drops below 95-93 – ask the patien “take a deep breath, please a few times”
- continuous reflections what we are doing regarding IV competencies
- varifiable CPD hours
- supervised clinical practice
- mentoring as an approved process
- log book of experience
- audit of sedation practice
- competence in rescue skills (ILS, ALS)
- IACSD section about IV sedation
- clinical governance
- IV for > 12 years old in Primary Care
Patient should not eat or drink 6-8 hours prior to their IV sedation appointment?. Controversial.
Aa companion is required to take patient to and from the dental office (relative, parent, legal guardian). This escort must be over the age of 18 and personally known to you. They must arrive and remain in the building with you. They must be able to escort you home and care for you for the rest of the day.
Patients are encouraged to wear loose, comfortable clothing and shoes
Patient will be closely monitor throughout the entire appointment by tracking blood pressure, heart rate and rhythm, oxygen level, and pulse.
Patient should not drive or operate machinery for at least 24 hours after the end of your appointment. If patient experiences any nausea after treatment, dentist can usually provide a prescription to help.
Patients are encouraged to sleep and drink plenty of water and clear fluids for the remainder of the day.
Until the following day after patient have had IV sedation:
• should not travel alone – travel home with your escort, by car if possible.
• should not drive or ride a bicycle or a motorcycle.
• should not use machinery.
• should not drink alcohol.
• should not return to work or sign legal documents.
Topical EMLA or AMETOP before cannulation, 45 mints up to 1 hours before.
Usually 24G cannula is used
How many attempts of IV cannulation before giving up as impossible to find a suitable vain (very narrow, fragile, not visible) ? 2 or 3 or more? good practice to pass on cannula to someone more experienced after 2 attemts
Combination of oral premedication + IV, buccal sedation + IV, intranasal sedation + IV may work better and more efficient for some patients
Standard dose of midazolam for adults: up to 5mg (vast majority of patientss), sometimes 6-10mg, very occasionally 11-15mg. Maximum dose 20 mg
If only one/single dose of sedative agent recorded in clinical records – it suggests that patient(s) was oversedated ! To keep comprehensive clinical notes.
Sedative agent must be titrated and this information has to be in patient notes (cannot be in a bolus !)
Is fasting necessary for IV sedation ? – lots of controversions, no clear evidence based data, patient can feel uncomfortable/unwell during procedure if did not have any meal for a long time, experienced sedationists do not recommend fasting. Clear guidelines needed.
Index of Sedation Treatment Needs can be used ot assess need for sedation
MDAS scale and scores to assess level of anxiety
Bispectral Index Monitoring can be useful.
ELLIS sedation scale can be applied to assess patient reactions.
Some sedationists (eg. ‘mobile’) prefer to carry additional full resuscitation kit in their car, including extra AED just in case of any problems with standard kit stored and kept in practive as they are not familiar with facilities in different clinics.