Conscious sedation: Pharmacology.
Patient selection factors.

BASIC AND ADVANCED

The selection of the most appropriate agents for each patient need to take many factors into account:

Proposed dental treatment

The type and complexity of the dental procedure are important factors that should be considered when selecting the most appropriate sedation agent for a patient. For example, a simple dental cleaning may require a lighter sedation such as nitrous oxide/oxygen, while a more complex procedure such as a oral surgery may require a stronger sedative such as propofol.

Age and body weight

Younger and smaller patients may require lower doses of sedatives to achieve the same level of sedation as larger and older patients.

For example, in the case of nitrous oxide/oxygen sedation, the flow rate of the gas mixture may need to be adjusted to account for differences in lung capacity and airway resistance between patients of different ages and sizes. Similarly, the dosage of midazolam and other sedatives may need to be reduced for paediatric patients to minimise the risk of side effects such as respiratory depression.

It's also important to consider age-related changes in drug metabolism and clearance. Older patients may have reduced liver and kidney function, which can affect the pharmacokinetics of sedative agents and increase the risk of drug accumulation and toxicity. Therefore, careful monitoring and adjustment of dosage may be necessary in elderly patients.

Degree of anxiety

Patients with mild to moderate anxiety can often be effectively managed with midazolam, or nitrous oxide / oxygen.

For patients with more severe anxiety or phobias, stronger sedatives may be necessary to achieve the desired level of sedation. Propofol is a potent sedative that is commonly used for deep sedation in more complex dental procedures, such as oral surgery. Opioids are another class of sedatives that can provide potent pain relief and sedation, making them useful for procedures that are likely to cause significant pain or discomfort.

Medical history

It is important to obtain a complete medical history that includes the patient's current medications, allergies, and any significant medical conditions. This information can help identify potential contraindications or drug interactions with sedative agents.

Patients with certain medical conditions may require special considerations when undergoing sedation. For example, patients with a history of respiratory problems, such as asthma or chronic obstructive pulmonary disease (COPD), may be at higher risk of respiratory depression when using certain sedatives, such as opioids. Patients with cardiovascular disease or hypertension may also require careful monitoring during sedation.

Physical examination

Physical examination is another important factor in determining the appropriateness of sedation. This includes assessing the patient's airway, respiratory status, and cardiovascular function. Patients with a compromised airway or compromised respiratory function may be at higher risk of complications during sedation.

Patients with compromised cardiovascular function may require special considerations during sedation, such as careful monitoring of blood pressure and heart rate.

Social history

The healthcare provider should take a thorough history of the patient's substance use, including alcohol, tobacco, and other illicit drugs, to identify any potential risk factors for abuse or addiction. Patients who have a history of substance abuse may require alternative methods of sedation or may need to be referred to a specialist for management of their sedation needs.

In addition, patients with a history of psychiatric illness or behavioural disorders may also be at higher risk of adverse effects from sedative agents, and as such, their medical history should be thoroughly evaluated to identify any potential risk factors. The healthcare provider may need to consult with a mental health specialist or modify the sedation approach to ensure the safety and well-being of the patient.

Healthcare environment

The healthcare environment plays an important role in determining the type and level of sedation that is appropriate for a given procedure. Some procedures may be safely performed in a dental office or clinic with minimal sedation, while others may require more intensive monitoring and support.

For example, propofol is a potent sedative agent that requires continuous monitoring of essential signs, respiratory function, and level of consciousness. It is often administered in a hospital or specialised sedation centre where trained healthcare professionals are available to monitor the patient and respond to any adverse events.

On the other hand, nitrous oxide/oxygen sedation can often be safely administered in a dental office or clinic with minimal monitoring. This type of sedation is self-administered by the patient, with the dentist or dental hygienist monitoring the patient's essential signs and level of consciousness.

Healthcare team sedation training and experience

Only healthcare professionals who are properly trained and experienced in sedation should administer sedatives, and the team should be equipped to manage any potential complications or adverse reactions that may arise.