21: Intravenous Moderate Sedation: Rationale

chapter 21 Intravenous Moderate Sedation: Rationale

General anesthesia has a long history in dentistry, starting with Drs. Horace Wells and William T.G. Morton in the mid-1800s. IV sedation is a relatively new technique in dentistry. It is only in the past 30 to 40 years that IV moderate sedation has gained a foothold. Until the late 1960s, the IV route was used almost exclusively by oral and maxillofacial surgeons primarily because their postdoctoral training placed great emphasis on the IV route of drug administration. Until recently, most dental schools in the United States did not include training in IV drug administration in their curricula, and today a scant few courses are available wherein the postgraduate dentist can receive such training. The past 20 years, however, have seen the implementation of predoctoral courses in IV moderate sedation by a small, but still growing, number of U.S. dental schools. Because of this and the present availability of a handful of excellent postgraduate programs in IV moderate sedation and the now increasing availability of 2-year residencies in general anesthesia for dentists, the number of dentists using IV moderate sedation has grown. It is impossible to even guess at the number of dentists (excluding oral and maxillofacial surgeons) employing the IV route today; however, for the patient requiring this mode of treatment, it has become easier to locate a dentist who administers IV moderate sedation for nonsurgical procedures.

A factor that deterred many dentists from the use of IV moderate sedation was the high cost of professional liability insurance. The 1980s saw a dramatic increase in the cost of liability insurance in many areas of life in the United States, not only in the health professions. However, the fact was that the cost of liability insurance for a dentist using IV conscious sedation (as it was then termed) was, in many states, prohibitively high. This became a major consideration in a dentist’s decision whether to use this valuable technique of patient management. As the mid-1990s arrived, the cost of liability insurance leveled off and in certain circumstances (e.g., a periodontist using IV moderate sedation in the state of California) actually decreased. As more complete risk assessment surveys were completed, the cost of liability insurance for dentists using IV moderate sedation continued along this promising pathway.

ADVANTAGES

DISADVANTAGES

2. Complications may arise at the venipuncture site. As discussed in Chapter 27, a variety of minor and some major complications can develop at the venipuncture site. These include hematoma, phlebitis, and intraarterial injection of a drug.
5. Although the depth of sedation provided by intravenously administered drugs can be increased rapidly (by administration of additional drug), the converse is not true. Many intravenously administered drugs cannot be reversed by specific drug antagonists. Although antagonists do exist for several drug groups, specifically opioids, benzodiazepines, and anticholinergics, they are not recommended for routine administration.13 Should a patient become overly sedated (deep instead of moderate; moderate instead of minimal), the initial, and most effective, management in all situations is the maintenance of basic life support: assess the patient’s airway, assist or support ventilation, and provide for the effective circulation of oxygenated blood. Following these steps (P-A-B-C [basic life support]) consideration may be given to antidotal drug therapy.

Box 21-1 summarizes the advantages and disadvantages of the IV route of drug administration.

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Jan 5, 2015 | Posted by in General Dentistry | Comments Off on 21: Intravenous Moderate Sedation: Rationale
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