IV sedation and NO sedation

[Smilemaker100]

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Hello (for the third time 😀 )

I was wondering how many dentists practice IV sedation and nitrous oxide sedation. Thanks! 🙂

 

[critterbug]

I shadowed a dentist that was certified to practice IV sedation. Never got to see it though. From what I understand, it is a very risky procedure. they don't just let any dentist do it.

 

[UBTom]

Lots of oral surgeons do conscious sedation... The most common combo I've seen on my externships and rotations: Induce with propofol, then administer midazolam and fentanyl.

Pediatric dentists usually know how to do N2O sedation.. Some GPs do as well.

I don't know how common these sedation methods would be with endos and periodontists though. Prosthodontists and orthodontists rarely have to use sedation...

HTH!

 

[Bitters]

Induce with diprivan? Are you crazy man, were not doing general anesthesia in the office. "Induce" is a specifice term used prior to intubation.

Drugs I use for sedation, and from what I gather a fairly common cocktail

Versed 4-6 mg
fentenyl 50-100 mcg
phenergan 6.25-12.5 mg
decadron 8 mg

This combination works well for about 80% of the sedations. Sometimes you get patients that have an atypical rxn to these drugs and you will need to then switch to propofol giving them a bolos or setting up a drip.

With children sometimes we will give them the "harpoon" adding other agents such a ketamine, and glycopyrolate.

Sedation is a very effective way to manage patients, duh they cant talk. It is relatively safe.

The difficult part is not administering the drugs. You must be able to choose the correct patients for the procedure by knowing a complete medical hx, and knowing what to do in an emergency situation.

Imagine sedating a patient and their pulse ox drops to 75, are non responsive to pain. Do you know how to intubate the patient if necessary. I am sure that everyone that has training in sedation learns intubate, but real life is more complicated than a rubber model. It takes practice and experience. A lot of it.

 

[UBTom]

Induce with diprivan? Are you crazy man, were not doing general anesthesia in the office.

Wrong. Diprivan IS commonly used in conscious sedation for oral surgery, as you can see from the replies of our colleagues below.

Since you are only a 2nd-year OMS resident who has not seen a wide range of practice, I suppose it never occurred to you that different places might actually do things a bit differently.

Yes, propofol is exactly what I saw used in doing conscious sedation in the OMFS clinics at four places where I've visited for rotations/externships: Buffalo General Hospital, Erie County Medical Center, Bellevue Hospital Center/NYU and Long Island Jewish.

If you have a problem with that, I defer you to the program directors at a few of those places if you wish to further inquire/debate/call them crazy for the use of diprivan at their institutions:

Richard Hall, DDS MD PhD: [email protected]
Vasiliki Karlis, DMD MD: [email protected]

Go ahead. You may safely assume that they are oral surgeons. Though they probably would not take kindly to some egotistical 2nd-year OMS resident calling them "crazy."

Consider yourself gently rebuked; you need to realize that your way isn't the only way.

 

[USC2003]

As an OMFS resident I can tell you that propofol is used routinely by oral surgeons when sedating patients. By definition when using propofol you are perfoming general anesthesia, even though you are not giving an induction dose. This is why oral surgeons need GA (general anesthesia) permits in their office.

 

[Dr.SpongeBobDDS]

Dang, I just sent off some cruel e-mails ridiculing Drs. Hall and Karlis for their idiotic use of propofol during routine sedation. Maybe they won't remember me when I apply to their programs in 2 yrs. 😉

 

[Frank Cavitation]

In terms of usage in a general practice, any recommendations with regards to sedative cocktail vs. NO? Is there something that relaxes the patient with lower risk of complications? Both IV and propofol sound a bit too much for me 🙂

 

[UBTom]

Yep... N2O is far more common in general practice offices.

My older sister is an ABA-certified anesthesiologist and she does travel to dental offices occasionally to perform IV sedation. Those are usually for patients who need a lot of work done in one go... And can afford it. 😀

to DrSpongeBob: LOL, I wouldn't worry about Dr. Hall... He is the nicest/funniest guy you will ever meet. The only thing that would ever piss him off is if you kill/maim a patient on his watch. 😉

 

[q8dentist]

hi, all,, well he topic is intresting since i've been taking an anesthesia selective class at the pittsburgh dental school for 2 years now,,,

we started during our 3rd year, after completeing this class we will be certified to do concious sedation wich include N2O. the class is really intresting we do rotations at the special need clinic, oral surgury , perio and implant center. about the drugs we use most of the cases we use the following

versed, propofol , ketamine fentnyl.

if it a surgury case this we add decadron for it anti inflimatory action,
we also use ketamine for uncoporative patients we give them 1-2 gm / kg IM

to be able to start the iv , ,,

we use sometimes glycopyrolate for its antisialagogue actions but we rarely do,

 

[Frank Cavitation]

Thanks for the responses. Not to hijack this thread, but I have more questions on this topic. Suppose a patient coming in needs basic treatment (exo or filling) but does not have the mental ability to understand instructions (very old, or mentally disadvantaged). If I have nitrous training would this be enough to make sure they won't bite down on the bur, or interfere with forceps? Should I refer them somewhere? This could be further complicated if this was a rural setting where the patient's family does not wish to put in the time/money to go 100s of miles for a specialist 🙁

 

[ToothMonkey]

Does anyone know how obtaining anesthesia permits affect one's malpractice rates? I imagine the resulting premium hike must be pretty hefty.

 

[q8dentist]

to frack cavitaions,
one of the indications to use n2o is the coporation of the patinet, because the only thing n2o do is to reduce the anxiety of the patient thats all it also has a weak analgesic effects , so using it to for an uncoporative patient will not be agood thing , if the main reason to use it is to kinda to control the movment of the patient. i would ask an anesthesiologist to come and do iv sedation on the patient

 

[no2thdk999]

Does anyone know how obtaining anesthesia permits affect one's malpractice rates? I imagine the resulting premium hike must be pretty hefty.

It depends on the carrier. Some do not charge any differently, some charge a pretty penny extra.

IV sedation in well trained hands is a very safe procedure, I think you could argue that for many patients treatment would be safer with IV sedation than without.

JMHO
Rob

 

[succedaneous32]

Hope you guys do not mind if I respond, but I have been an assistant for 14 years and only encountered 1 doctor who would do IV sedation in his practice. This is genral dentistry. I do believe that his malpractice was very high. Most GP's don't want to touch that with a ten foot pole. There were several times when someone, usually children, did not respond well to the "cocktail" administered and time froze until we got them to go from a lovely shade of smurf blue to nice red cheeks. It is stressfull. There is mostly n2o in GP. To answer the question about having a difficult patient and whether to administer n2o or what then, experience has shown that most doctors will go with their gut feeling and their own capabilities. If you end up having lots of experience with that then fine- if not, don't be afraid to refer someone. Referalls are an excellent option. Just don't bite off more than you can chew. Oh, as far as oral meds like Noctec and valium, some do that too, but I have heard that NOctec resulted in some deaths in California, so it is not widely used. I believe the problem lied with the parents giving the child the dose instead of having them come in early, let the doctor administer and have them wait around until the drug takes affect. Usually, it is a go but there are some patients, especially kids that bounce off the walls in your waiting room. They go home! 🙂 In a nutshell, it is not that common for IV sedation in general dentistry. 😉