22

Chapter
Conscious Sedation
Nikhil Marwah, Hind Pal Bhatia

Chapter outline
• Clinical Guidelines for use of Conscious Sedation by • Drugs used for Conscious Sedation
Dentists • Reversal Agents
• Instructions to the Parents for Conscious Sedation • Complications Associated with Moderate or Deep
• Sedation Techniques Sedation
• Nitrous Oxide Sedation

Most children can be managed effectively using the techniques health throughout life. This implies two main dimensions in
outlined in basic behavior guidance. These basic behavior pediatric oral care: (1) to keep the oral environment healthy,
guidance techniques should form the foundation for all of and (2) to keep the patient capable of, and willing to utilize
the management activities provided by the dentist. Children, the dental service. In recognition of the expanding need for
however, occasionally present with behavioral considerations both the elective and emergency use of sedative agents and
that require more advanced techniques. These children often the importance of delivering painless treatment to children,
cannot cooperate due to lack of psychological or emotional guideline for the use of sedative agents among children are
maturity and/or mental, physical, or medical disability. The important. Pediatric dentists should be aware that sedation
advanced behavior guidance techniques commonly used represents a continuum. Thus, a patient may move easily from
include protective stabilization and sedation. a light level of sedation to a deeper level, which may result
Current understanding of pediatric oral health includes in the loss of the patient’s protective reflexes. The distinction
absence of dental fear and anxiety as well as healthy oral between conscious sedation and deep sedation is made for
structures with the aim of forming the basis for good oral the purpose of describing the level of monitoring needed, as
well as the responsibility of the dentist.

Objectives of sedation in pediatric dentistry DEFINITIONS

• For the child
– Reduce fear and perception of pain during the treatment Conscious sedation1: A minimally depressed level of con-
– Facilitate coping with the treatment sciousness that retains the patient’s ability to independently
– Prevent development of dental fear and anxiety and continuously maintain an airway and respond appro-
– Minimize physical discomfort and pain priately to physical stimulation or verbal command and that
– Control behavior and/or movement so as to allow the safe is produced by a pharmacological or nonpharmacological
completion of the procedure method or a combination thereof.
– Minimize psychological trauma, and maximize the potential
for amnesia
Deep sedation1: A drug-induced depression of consciousness
• For the dentist during which patients cannot be easily aroused but respond
– Facilitate accomplishment of dental procedures purposefully following repeated or painful stimulation. The
– Reduce stress and unpleasant emotions
ability to independently maintain ventilatory function may
– Prevent “burn-out” syndrome
be impaired. Patients may require assistance in maintaining
 Chapter 22 Conscious Sedation 243
Objectives of conscious sedation2,3 Goals of conscious sedation Indications2,3
• Reduce or eliminate anxiety • To provide the most comfortable, efficient • Lack of psychological or emotional
• Reduce untoward movement and and high quality dental service for the maturity
reaction to dental treatment patient • Medical, physical, cognitive disability
• Enhance communication and patient • To control inappropriate behavior that • Fearful, highly anxious or obstreperous
cooperation interferes with such provision of care patient
• Raise the pain reaction threshold • To produce in the patient a positive • A patient whose gag reflex interferes
• Increase tolerance for longer psychologic attitude towards future care with dental care
appointments • To promote patient welfare and safety • A cooperative child undergoing a lengthy
• Aid in treatment of the mentally/ • To return the patient to a physiologic dental procedure
physically disabled or medically state in which safe discharge is possible • Certain patients with special health care
compromised patient needs
• Reduce gagging • A patient for whom profound local
• Potentiate the effect of sedatives anesthesia cannot be obtained

a patent airway, and spontaneous ventilation may be inade-

quate. Cardiovascular function is usually maintained. may consist of a review of their current medical history
and medication use.
General anesthesia1: A drug-induced loss of consciousness
during which patients are not arousable, even by painful
stimulation. The ability to independently maintain ventilatory care physician or consulting medical specialist.
function is often impaired. Patients often require assistance in
maintaining a patent airway, and positive pressure ventilation Documentation before Sedation
may be required because of depressed spontaneous ventilation
or drug-induced depression of neuromuscular function. Documentation shall include, but not be limited to, the
Cardiovascular function may be impaired. guidelines that follow:
Informed consent: The patient record shall document that
Minimal sedation (old terminology “Anxiolysis”): A drug- appropriate informed consent was obtained according to
induced state during which patients respond normally to ver- local, state, and institutional requirements.
bal commands. Although cognitive function and coordination
may be impaired, ventilatory and cardiovascular functions are person.
unaffected.
instructions to the responsible person. Information
CLINICAL GUIDELINES FOR USE OF shall include objectives of the sedation and anticipated
CONSCIOUS SEDATION BY DENTISTS1 changes in behavior during and after sedation.

(According to American Dental Association, October 2012). for infants and toddlers who will be transported home in a
car safety seat regarding the need to carefully observe the
child’s head position so as to avoid airway obstruction.
Patient Evaluation
her associates shall be provided to all patients and their
evaluated prior to the start of any sedative procedure. families.

Classification of patient selection (According to American Society of Anesthesiologists)4

ASA Physical Status I A normal healthy patient
ASA Physical Status II A patient with mild systemic disease
ASA Physical Status III A patient with severe systemic disease
ASA Physical Status IV A patient with severe systemic disease that is a constant threat to life
ASA Physical Status V A moribund patient who is not expected to survive without the operation
ASA Physical Status VI A declared brain-dead patient whose organs are being removed for donor purposes
E Emergency operation of any variety (used to modify one of the above classifications)
244 Section 5 Behavioral Pedodontics

appropriate dietary precautions. gases other than oxygen or air are used.

Preoperative Preparation Preparation and Setting-up

for Sedation Procedures
advised regarding the procedure associated with the
delivery of any sedative agents and informed consent for approach so as to not overlook having an important drug,
the proposed sedation must be obtained. piece of equipment, or monitor that should be immediately
available at the time of a developing emergency.
necessary to deliver oxygen under positive pressure must
be completed. allows the same setup and checklist for every procedure.
A commonly used acronym useful in planning and
behavior prohibits such determination.

deemed appropriate. ing suction apparatus

based on the sedative technique prescribed (Table 22.1). meters/other devices to allow its delivery
Airway:
given to the patient, parent, escort, guardian or care Pharmacy: All the basic drugs needed to support
giver. life during an emergency, including antagonists
Monitors: Functioning pulse oximeter and other
monitors as appropriate like capnograph
Personnel and Equipment Requirements

for healthcare providers must be present in addition to Monitoring during Sedation

the dentist.

the patient being treated must be immediately available. trained individual, must remain in the operatory
during active dental treatment to monitor the patient
continuously until the patient meets the criteria for
calibrated. discharge to the recovery area.

device that prohibits the delivery of less than 30 percent with monitoring techniques and equipment.
oxygen or (2) an appropriately calibrated and functioning
ventilation.

TABLE 22.1: Appropriate intake of food and liquids before elective sedation*

Ingested material Minimum fasting period (h)
Clear liquids, water, fruit juices without pulp, carbonated beverages, clear tea, black coffee 2
Breast milk 4
Infant formula 6
Nonhuman milk because nonhuman milk is similar to solids in gastric emptying time, the amount ingested must 6
be considered when determining an appropriate fasting period
Light meal: A light meal typically consists of toast and clear liquids. Meals that include fried or fatty foods or 6
meat may prolong gastric emptying time. Both the amount and type of foods ingested must be considered when
determining an appropriate fasting period.
* American Society of Anesthesiologists. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of
pulmonary aspiration: Application to healthy patients undergoing elective procedures. A report of the American Society of Anesthesiologists.
Available at “http://www.asahq.org/publicationsAndServices/npoguide.html”.
 Chapter 22 Conscious Sedation 245
Discharge criteria
• Cardiovascular function and airway patency are satisfactory
and stable
• The patient is easily arousable
• The patient can talk (if age appropriate)
• The patient can sit up unaided (if age appropriate)
• Presedation level of responsiveness achieved
• The state of hydration is adequate

given to the patient, parent, escort, guardian or care giver.

Fig. 22.1: Capnography machine Emergency Management

Oxygenation
dental procedure until the patient returns to the intended
continuously. level of sedation.

available at all times to the dentist for usage.

oxygen carried on hemoglobin in the arterial blood. It
2, perfusion management, adequacy of the facility and staff, diagnosis
and heart rate. Its advantages are continuous monitoring,
multiple sites of usage, noninvasive and user friendly. ration of minimal sedation and providing the equipment
and protocols for patient rescue.
Ventilation

verify respirations continuously.

Summary of conscious sedation
provide the digital display of a numeric value along with
the waveform and it gives a digital display of the CO2 on
inspiration and expiration. The principle of capnography
is: Gas is diverted from the patient’s airway—A beam of
infrared light is passed through the sampled gas—CO2
molecules in the light path absorb some of the infrared
light waves—Capnography measures end tidal carbon
2).

Circulation

operatively, postoperatively and intraoperatively as necessary

(unless the patient is unable to tolerate such monitoring).

Recovery and Discharge

available if a separate recovery area is utilized.

must monitor the patient during recovery until the patient

is ready for discharge by the dentist.
246 Section 5 Behavioral Pedodontics

INSTRUCTIONS TO THE PARENTS SEDATION TECHNIQUES

FOR CONSCIOUS SEDATION
There are a variety of methods for producing sedation or
Eating and drinking To avoid vomiting and complications during alteration of mood in the pediatric patient. These systemic
treatment with sedation, do not allow your procedures are based on thoughtful utilization of various
child any food or drink (even water) unless drugs that produce sedation as one of their principal effects.
directed by your doctor. The following
schedule should be followed: rectal, submucosal, intramuscular, or intravenous routes.
• No milk or solid food, midnight before the
scheduled procedure administration to maximize effect and increase safety, as well
• Children ages 0–3 years, clear liquids up to as patient acceptability, are common. The primary objective
4 hours before the procedure
of these techniques is to produce a quiescent patient to ensure
• Children ages 3–6 years, clear liquids up to
the best quality of care and to help train a child to willingly
6 hours before the procedure
• Children ages 7 years or greater, clear accept dental care. Another objective might be to accomplish
liquids up to 8 hours before the procedures a more complex or lengthy treatment plan in a shorter period
Change in health Any change in the child’s health, especially the by lengthening appointment times, thereby reducing the
development of a cold or fever, within 7 days
before the day of treatment is very important. sedation are:
For the child’s safety, a new appointment may
be made for another day
Arriving A responsible adult must accompany the Inhalation Sedation
patient to the dental office and must remain
until treatment is completed. Plan to arrive
pediatric dentistry.
early for your appointment
Medications Give your child only those medications that
he or she takes routinely, such as seizure terms of onset and recovery.
medications or prophylactic antibiotics, and
those prescribed by your child’s physician.
Do not give your child any other medicines,
before or after treatment, without checking sedation and reduces atmospheric pollution.
with dental office
Activities Do not plan to permit activities for the child
after treatment. Allow the child to rest closely
supervise any activity for the remainder of the
day
Getting home The patient must be accompanied by a
responsible adult. Someone should be
available to drive the patient home. The
child should be closely watched for signs of
breathing difficulty and carefully secured in a
car seat or seat belt during transportation
After treatment After treatment, the first drink should be plain
water. Sweet drinks can be given next. Small
drinks taken repeatedly are preferable to
taking single with large amounts
Temperature The child’s temperature may be elevated
for the first 24 hours after treatment.
Acetaminophen every 3–4 hours and fluids
will help alleviate this condition Fig. 22.2: Inhalational sedation
Seek advice • If vomiting persists beyond 4 hours
• If the temperature remains elevated. Oral Sedation
beyond 24 hours or goes above 101°F
• If there is any difficulty in breathing
• If any other matter causes your concern drug administration.
 Chapter 22 Conscious Sedation 247
within the facility where the dental procedure is to take
place. Children who are given an oral sedative should
reversal of unwanted effect and slow recovery time. be placed in a quiet room together with their escort and
a competent member of staff and should be monitored
combination therapy. clinically and electronically.

prescribed and administered by the operating dentist

Intramuscular Sedation

additional training of the operator is required. For most

patients the upper outer quadrant of gluteal region is
safest but in small children anterior thigh (vastus lateralis

provision of a general anesthetic might carry a lower risk

child.

Submucosal Sedation

Fig. 22.3: Oral sedation

A B

C D E
Figs 22.4A to E: Site of intramuscular sedation
248 Section 5 Behavioral Pedodontics

mable, inert gas and is compressed in cylinders at 750

psi as a liquid that vaporizes on release. It has a blood gas

due to low solubility in blood.

concentration (MAC) value in excess of one atmosphere,

rendering full anesthesia without hypoxemia impossible
at normal atmospheric air pressure. Poor tissue solubility
ensures its effect is characterized by rapid onset and fast
recovery.

by the psychological preparation of the patient.

Indications
Fig. 22.5: IV sedation

to enable them to accept dental treatment better and to

Intravenous Sedation facilitate coping across sequential visits.

parentral sedation (Fig. 22.5) next to inhalation.

Contraindications

of phlebitis and hematoma at the site.

cooperative children. Dentists should consider whether

the provision of an elective general anesthetic might be
preferable in such circumstances.
Procedure of Administration (Fig. 22.6)6,7
recommended for adolescents who are psychologically
and emotionally suitable.

an experienced dental sedationist with a trained dental

nurse in an appropriate facility.

clinical observation.

adolescents.

Rectal Sedation

NITROUS OXIDE SEDATION5,6

ment of conscious sedation and that is nitrous oxide.

dentists.
 Chapter 22 Conscious Sedation 249

Fig. 22.6: Nitrous oxide sedation equipment and procedure

Clinical Signs of Sedation8

These signs are clues for the clinician in determining whether
the young child has reached a sedative state consistent with
good behavior and pharmacologic effectiveness.

Objective Signs

nitrous oxide administration.

the patient’s face, hands, legs, and feet to determine the

effects of nitrous oxide.

(5) speaking; (6) laughing; (7) open or closed hands; (8)

limp legs; and (9) abducted feet.

Subjective Symptoms (Fig. 22.7)

the nitrous oxide effects. Fig. 22.7: Beery criteria for correct drawing of selected figures of the
Bender Visual Motor Gestalt Test18

overall condition were asked prior to and 5 minutes after

nitrous oxide administration.
250 Section 5 Behavioral Pedodontics

Psychomotor Effects Precautions11

9 before colored, which it is not, it would tend to descend from the

and 5 minutes after nitrous oxide was administered. patient’s level in the reclined position to the floor. This gas
10 of the child

(Fig. 22.7).
systems could be used to flush out the used gases from the
bottom of the operatory and fresh air pumped in from the
Advantages
ceiling.2

anesthesia. and nasal hood may have some odor that the child

vascular and respiratory function and the laryngeal reflex. flavor the inside of the nasal hood by using fluoride foam
or drops of flavored liquid to produce vapors that the child
with other sedatives may rapidly produce a state of deep 2

sedation or general anesthesia. Diffusion hypoxia may occur as the sedation is reversed
at the termination of the procedure. The nitrous oxide
escapes into the alveoli with such rapidity that the oxygen
Disadvantages
present becomes diluted; thus the oxygen–carbon dioxide
exchange is disrupted and a period of hypoxia is created.
are nausea.

recreational abuse. effect, the patient should be oxygenated for 3 to 5 minutes

after a sedation procedure, if for no other reason than to
12 allow for proper nasal hood evacuation of the exhaled gas.

Recommendations for controlling nitrous oxide exposure in the dental office

Equipment • Properly installed nitrous oxide delivery system
• Appropriate scavenging equipment with a readily visible and accurate flowmeter
• Vacuum pump with capacity up to 45 liters of air per minute per work station
• Variety of mask sizes to ensure proper fit
Ventilation • Vacuum exhaust and ventilation exhaust vented outside
• Outside venting not in close proximity to fresh air vents
• Good room air mixing for general ventilation
Inspections • With each use and when gas cylinder is changed, pressure connections tested for leaks using a soap solution or a
portable infrared spectrophotometer
• Daily, price to first use, inspected for worn parts, cracks, holes or tears, and replaced as necessary
• Appropriate flow rates (up to 45 liters/min or per manufacturer’s recommendations) verified
Clients Before administration
• Use properly sized masks to ensure a good, comfortable fit
• Check for over- or under-inflation of reservoir (breathing) bag while the patient is breathing oxygen (before nitrous
oxide administration)
During administration
• Minimize talking and mouth breathing by patient while mask is in place
• Reservoir bag periodically inspected for changes in tidal volume
• Vacuum flow rate verified
After administration
• 100% oxygen delivered to patient for five minutes before removing mask to purge patient and system of residual
nitrous oxide
• System oxygen flush should not be used
Dental personnel • Periodic (i.e. semi-annual) sampling of dental personnel, especially chair-side personnel exposed to nitrous oxide
(e.g. with a diffusive sampler, such as a dosimeter or infrared spectrophotometer)
Source: ADA council on scientific affairs and the ADA council on dental practice
 Chapter 22 Conscious Sedation 251
Special indications nitrous oxide-oxygen inhalation sedation
Cardiovascular disease N2O-O2 inhalation sedation can minimize the risk of myocardial infarction
Cerebrovascular disease Patient who has cerebrovascular disease, can receive N2O-O2 for stress/anxiety reduction
Respiratory disease Patients with bronchial asthma can receive nitrous oxide because it is non-irritating to the bronchial and
pulmonary tissues
Hepatic disease N2O-O2 is not bio-transformed anywhere in the body, it can be used in patients with hepatic disease.
Epilepsy and other seizure N2O-O2 can be useful in these patients to avoid stress
(Bowen DM. Aiding in administration of nitrous oxide analgesia. Idaho: Idaho State Board of Dentistry: Jan. 2005)

DRUGS USED FOR CONSCIOUS SEDATION muscle twitching, and seizures.

Opioids Fentanyl (Sublimaze)

propensity to cause respiratory depression. rapid onset and shorter

duration than morphine.
analgesia include morphine, meperidine and fentanyl.
potent than morphine.
Morphine
10 minutes (IM).

minutes for IM doses. fentanyl is 10 minutes

(IM). (IM).

30 to 60 minutes.
large doses can produce
obtundation and even higher doses when given rapidly intravenous can produce
coma. skeletal muscle rigidity called “stiff chest syndrome.”

prolonged postoperative response associated with surgery or invasive procedures

somnolence, respiratory and also depresses the respiratory center in the brainstem
depression, nausea, so that normal response to hypoxia and hypercarbia is
vomiting, and itching. reduced.

Meperidine (Demerol) Benzodiazepines

commonly used for moderate sedation.

diazepines have amnesic, anxiolytic, anticonvulsive and

10 to 15 minutes (IM). hypnotic effects.

sedation include diazepam, lorazepam and midazolam.

Diazepam (Valium)/Lorazepam (Ativan)

morphine. They produce moderate effects on tidal volume

and slow respiratory rate. approximately 5 times as potent as diazepam.
252 Section 5 Behavioral Pedodontics

cardiac output and peripheral vascular resistance. tract and produces its peak effect in 30 minutes.3

of action, they may not be suitable for outpatient

procedures. weight, oral midazolam has been found to be a useful
sedative agent for pediatric dental outpatients.

amnesia when used preoperatively in pediatric patients.

duration of action that makes its use limited to short

dental procedures only.

Intranasal Midazolam14

Midazolam (Versed) effect within 5 minutes of

administration.

or adult dental patients. is limited by the volume

of the solution, as large
children. volumes can cause coughing, sneezing and expulsion of
part of the drug.
clearance and elimination allow rapidity of onset and
speedy recovery. depression and transient burning, discomfort affecting
the nasal mucosa.
is reached within 20 minutes, faster via the rectal route in
nasal secretions or who suffer from an upper respiratory
off. The elimination half time is 2 hours, which facilitates a tract infection.
fast recovery.
environment.
IV Midazolam

in adults, there are few

studies to support its of administration (10–15 minutes).
routine use in the dental
management of anxious established as a premedication for anesthesia but its use
children. is limited by burning on application to the nasal mucosa

paradoxical excitement the bitter taste of midazolam reaching the oropharynx.

in children that is known by many as “Angry Child 7

Rectal Midazolam
Oral Midazolam12,13
required a low dosage
a sweetened mixture for delivery either via a drinking cup
or drawn into a needleless syringe and deposited in the tered according to the
explained diagram.

oral mixtures given approximately 20 to 30 minutes tions such as agitation,

before. excitement, restlessness

circulation, this decreases the drug’s bioavailability, blood oxygen levels, nausea and vomiting have been
reported.
venous administration.
 Chapter 22 Conscious Sedation 253

of hospital setup. incidence of adverse effects.

25 kilogram of 8 percent milligram of chloral hydrate and 4.5 percent milligram of

weight shall have Nembutal were found in Marilyn Monroe’s system, and Dr Thomas
Noguchi of the Los Angeles County Coroners office recorded cause
per kilogram bodyweight of death as acute barbiturate poisoning, resulting from a probable
with maximum dose 10 suicide.
mg midazolam.

before treatment starts.

Barbiturates chloral hydrate is rapid, drowsiness or arousable sleep

sedation is desired.
approximately 8 hours.
related respiratory depression. At lower doses, these
medications can also cause paradoxical excitation. doses, natural sleep is produced.

Methohexital15 depress blood pressure and respiratory rate and may

cause oxygen desaturation and prolonged drowsiness.

barbiturate with rapid onset. for drug abuse in earlier days. Marilyn

high lipid solubility allows intramuscular of chloral hydrate and possibly died
(IM), oral, or rectal administration. of its overdose.

in children with heart disease as

spontaneous movements within well as those with renal or hepatic
1 minute; patients usually wake up within impairment.
10 minutes.
Propofol16
may potentiate pain perception.

reflexes, myocardial depression. the dose required to produce a sedative effect is close to
that used to induce anesthesia.
Pentobarbital
Veerkamp et al. (1997) published an account of an
exploratory study where children, mainly with nursing
diagnostic studies. bottle caries, had teeth removed
using propofol administered by an
within 5 minutes, and effects should last between 30 to anesthetist.
60 minutes.
needed to know more about

Chloral Hydrate
Michael Jackson due to overdosing.

chlorinated derivative of
Dexmedetomidine (Precedex)
ethyl alcohol that can act
as an anesthetic when
administered in high a
doses. a short duration of action.
254 Section 5 Behavioral Pedodontics

sedation and provide analgesia while still

maintaining patient arousability and of flumazenil may be required.
respiratory function.
Naloxone
and anxiolytic effects after intravenous 2

administration. can be given intravenously, intramuscularly,

or subcutaneously but the preferred route of
effective sedation and reduces analgesic requirements. administration is intravenous.

allows the patient to be awakened and respond to verbal manner when possible.
commands, take neurological tests, and be interactive while
of naloxone. The neonatal preparation which contains
stimulus is removed, the patient returns to sleep. 0.02 mg/kg is not recommended. The dose for children is
0.1 mg/kg for children under 20 kg. The dose for children
over 20 kg is 2 mg.
Ketamine17
Parke-Davis effects of the opioids.
scientist Calvin Stevens and got FDA approval
in 1970. quite disturbed when they are awakened from sedation by
administering naloxone.
results in dissociation between the cortical and
limbic systems of the brain called dissociative
anesthesia. COMPLICATIONS ASSOCIATED WITH
MODERATE OR DEEP SEDATION18,19
from perceiving visual, auditory, and painful stimuli.

effects last 15 to 30 minutes. analgesia should be able to recognize a patient in respiratory

that is characteristic of dissociative anesthesia. complications are:

muscle tone and airway reflexes. depression causing hypoxia and hypercarbia.

cranial and intraocular pressures, hypertension, tachycardia hypotension.

and postemergence delirium (i.e. vivid nightmares).
reactions).
impairments, including memory problems.

owing to its dissociative properties.

Table 22.2. Airway Obstruction

REVERSAL AGENTS associated with moderate sedation.

or snoring, rocking chest movements, absence of breath

opioids. sounds, hypoxemia, hypercarbia.

responsibly utilize either of these classes of agents. of hypercarbia is respiratory center depression from
medications.
Flumazenil 2
and is the result of hypoventilation.
2
can be used to reverse the effects 2
of benzodiazepines and should be immediately 2 by pulse oximeter is less than 90 percent.
available when using benzodiazepines for If airway obstruction is suspected consider:
sedation. the patient’s head providing a head tilt, applying a chin
 TABLE 22.2: Summary of drugs use for conscious sedation
Drug Class & Dosing Guidelines (IV Administration) Onset, Peak Adverse Drug Reactions Comments Reversal
Mechanism of Effect, and
Action duration of
Action
Midazolam Benzodiazepine Adults 16–64 years of age: Onset: 1–3 min Respiratory and Advantages include quick onset and short Flumazenil
(Versed) (Binds to 0.05 mg/kg repeated every 2–3 minutes to adequate Peak Effect: 5–7 cardiovascular duration of action. Due to quick onset (0.2 mg
GABA receptor sedation up to a max dose of 2 mg/kg. (Small min depression may occur. and rapid clearance, is often the most over 15
resulting in CNB incremental doses of 1–3 mg every 2–3 minutes up to Duration of May also cause ataxic, satisfactory benzodiazepine for peri- seconds,
depression) an average total dose of 5 mg) Action: dizziness, hypotension, procedure sedation. Combine with an may repeat
Elderly (> 0.5) and those with COPD, congestive heart 20–30 min bradycardia, blurred opioid for painful procedures but reduce at 1 min as
failure, or chronic debilitation: vision, and paradoxical dose by 25–50%. needed)
0.02 mg/kg repeated every 2–3 minutes to adequate agitation.
sedation up to a max dose of 0.2 mg/kg (small
incremental doses of 0.5–1 mg every 2–3 min)
Lorazepam Benzodiazepine Adults 16–64 years of age: Onset: 3–7 min Respiratory and Compared to midazolam, has slower Flumazenil
(Ativan) (Binds to GABA 0.02–0.05 mg/kg repeated every 3–4 minutes up to a Peak Effect: cardiovascular onset and longer duration of action. In (0.2 mg
receptor max dose of 4 mg. (Small incremental doses of 1–2 mg 10–20 min depression may occur. upper end of dosing range listed, may over 15
resulting in CNS every 3–4 minutes up to a max dose of 4 mg) Duration of May also cause ataxia, causes dysphoria and confusion. Due seconds,
depression) Elderly (> 65) and those with COPD, congestive heart Action: 6–8 dizziness, hypotension, to slower onset and longer duration of may repeat
failure, or chronic debilitation: hours bradycardia, blurred action, has limited utility for procedural at 1 min as
0.02 mg/kg repeated every 3–4 minutes up to a max vision, and paradoxical sedation. Combine with an opioid for needed)
dose of 4 mg. agitation. painful procedures but reduce dose by
(Small incremental doses of 0.5–1 mg repeated every 25–50%.
3–4 minutes up to a max dose of 4 mg)
Diazepam Benzodiazepine Adults 16–64 years of age: Onset: 1–5 min Respiratory and Has a longer half-life and several long- Flumazenil
(Valium) (Binds to 5 mg which may be repeated every 5 minutes to a max Duration of cardiovascular acting active metabolites compared to (0.2 mg
GABA receptor dose of 20 mg Action: depression may occur. midazolam and lorazepam. Due to longer over 15
resulting in CNB Elderly (> 65) and those with COPD: 1–8 hours May also cause ataxia, and highly variable duration of action, has seconds,
depression) 2.5 mg which may be repeated every 5 minutes to a dizziness, hypotension, limited utility for procedural sedation. may repeat
max of 10 mg bradycardia, blurred May be useful for longer procedures such at 1 min as
vision, and paradoxical as HBO treatment. Use with caution in needed)
agitation. the elderly due to unpredictable duration
of action. Combine with an opioid for
painful procedures but reduce the dose
by 25–50%.
Fentanyl Opioid narcotic Adults 16–64 years of age: Onset: 1–2 min Hypotension, Advantages include quick onset and Naloxone
(Sublimaze) (Binds to opioid 0.5–1 mcg/kg given in small incremental doses of Peak Effect: bradycardia, respiratory short duration of action. Due to quick (0.4 mg
receptor in the 25–50 mcg up to a max dose of 250 mcg 10–15 min depression, nausea, onset and rapid clearance, is often the initially
CNS) Elderly (> 65): Duration of vomiting, constipation, most satisfactory opioid narcotic for followed
0.5–1 mcg/kg given in small incremental doses of 25 Action 30–60 biliary spasm, and skin peri-procedure sedation. Adverse effects by 0.1–0.2
mcg up to a max dose of 100 mcg. The elderly are more min rash are more common in the elderly. When mg every
susceptible to CNS depression. combined with benzodiazepines, use 2–3 min as
reduced initial doses of each. Causes less needed)
histamine release and is associated with
less hypotension and skin rash compared
with morphine.
Contd...
Chapter 22 Conscious Sedation
255
Contd...

Drug Class & Mechanism of Dosing Guidelines (IV Administration) Onset, Peak Adverse Drug Reactions Comments Reversal
Action Effect, and

256 Section 5
duration of
Action
Meperidine Opioid narcotic Adults 16–64 years of age: Onset: 5 min Hypotension, bradycardia, Has no major advantages over other opioids Naloxone
(Demerol) (Binds to opioid 25–50 mg incremental doses to a max dose of Peak Effect: respiratory depression, such as fentanyl and morphine, and is associated (0.4 mg initially
receptors in the CNS) 150 mg 1 hour nausea, vomiting, with a risk of seizures in patients with renal followed by
Elderly (> 0.5): Duration of constipation, biliary dysfunction. Use is not recommended in the 0.1–0.2 mg
25 mg incremental doses to a max dose Action: spasm, and skin rash. elderly due to increased risk of adverse effects every 2–3 mins
of 75 mg. 2–4 hours Seizures as a result of non- including seizures. When combined with as needed)
The elderly are more susceptible to CNS meperidine accumulation benzodiazepine, use reduced initial doses of each.
depression. in patients with renal
The elderly are also more susceptible to failure may also occure.
Behavioral Pedodontics

selzures form non-meperidine accumulation,

a metabolite of meperidine, as a result of
reduced renal function in the elderly.
Morphine Opioid narcotic Adults 16–64 years of age: Onset: 2–3 Hypotension, bradycardia, Slower onset and longer duration of activity Naloxone
(Binds to opioid 2–4 mg incremental doses every 5 minutes up min respiratory depression, compared to fentanyl. More histamine release (0.4 mg initially
receptors in the CNS) to a max dose of 10–20 mg Peak Effect: nausea, vomiting, associated with hypotension and itching followed by
Elderly (> 65): 20 min constipation, biliary compared to fentanyl. Adverse effects are more 0.1–0.2 mg
1–2 mg incremental doses every 5 minutes up Duration of spasm, and skin rash common in the elderly. When combined with every 2–3 mins
to a max dose of 10 mg. The elderly are more Action: benzodiazepines, use reduced initial doses of as needed)
susceptible to CNS depression with opioid 2–4 hours each.
narcotic drugs.
Propofol Hypnotic/anesthetic Adults 16–64 years of age: Onset: 30 Hypotension, heart Due to risk of hypotension, and bradycardia with
(Diprivan) hindered phenolic 10–20 mg incremental doses every 5 minutes sec block, asystole, and other bolus doses, use is restricted to monitored ICU/
compound as needed to a max dose of 100 mg. Give slow Duration of arrhythmias, bradycardia, ED patients and or use by anesthesia personnel.
(General anesthetic and IV push to avoid hypotension. Action and possible infection Has advantages of rapid onset and very short
sedative properties; Elderly (> 65): 10–15 min from lipid based vehicle. duration of action. Patients who are debilitated,
structurally unrelated to 10 mg incremental doses every 5 minutes Allergic reactions in cardio-vascularity compromized, hypovoiemic,
opioid, barbiturate, and as needed to max dose of 50 mg. Give slow patients with a history of elderly, or on concomitant beta blockers are at
benzodiazepine drugs) IV push to avoid hypotension which is more an egg allergy. greatest risk of hypotension. Has minimal to no
common in the elderly and in hypovolemic analgesic effects; combine with an analgesic
patients. agent for painful procedures.
Ketamine Dissociative general Adults 16–64 years of age: Onset: 1–2 Emergence CNS reactions In contrast to other sedative/analgesics, can cause
(Ketalar) anesthetic acetylcyclo- 0.2–1.0 mg/kg min including vivid dreams, hypertension and tachycardia and should be
hexanone agent May repeat as necessary up to a maximum Duration hallucinations, and avoided in patents with aneurysms, elevated ICP, or
(Produces a cataleptic- dose of 2 mg/kg. of Action: delirium; hypertension, hypertension. Adverse psychotic reactions may be
like state in which the Elderly (> 65): 15–30 min tachycardia; increased ICP; avoided by pre-treatment with benzodiazepines.
patient is dissociated 0.2–0.75 mg/kg tonic clonic movements; Many adult patients do not tolerate the negative
from the surrounding May repeat as necessary up to a maximum respiratory depression. CNS side-effects. Unlike other agents, produces
environment; Produces dose of 2 mg/kg. Wide dose range effects, both sedation and analgesia. Emergence psychotic
intense analgesia and with analgesic action at reactions may last longer than sedative/analgesic
sedation without causing low doses (≤ 0.2 mg/kg). effects.
hypotension)

Contd...
Contd...

Drug Class & Mechanism of Dosing Guidelines (IV Administration) Onset, Peak Adverse Drug Reactions Comments Reversal
Action Effect, and
duration of
Action
Thiopental Barbiturate hypnotic/ Adults 16–64 years of age: Onset: 1–2 min Hypotension, myocardial Short-acting barbiturate useful for
(Pentothal) anesthetic Incremental doses of 50–100 mg up to a Duration of depression, CNS and respiratory intubation. No analgesic effects.
(Depresses CNS activity by maximum of 3 mg/kg Action: 10–30 depression, nausea, vomiting, Inactive, debilitated, and elderly
binding to the barbiturate Elderly (> 65): min diarrihea, cramping, laryngospasm may be more susceptible to
site on GABA-receptor 25–50 mg incremental doses up to a maximum adverse effects. Increased toxicity
complex, enhancing GABA of 2 mg/kg. The elderly are more susceptible with other CNS depressants.
activity) to excessive sedation and smaller initial doses
should be utilized.
Pentobarbital Barbiturate Adults 16–64 years of age: Onset: Hypotension, cardiovascular Short-acting barbiturate useful
(Nembutal) (Sedative, hypnotic, and 100 mg every 1–3 minutes up to a maximum Within 1 minute depression, respiratory for pre-procedure sedation.
anticonvulsant properties; dose of 500 mg. Duration of depression, nausea, vomiting, No analgesic effects. Inactive,
increases GABA activity in Elderly (> 65): Action: 15 min laryngospasm debilitated, and elderly may be
the CNS) 50 mg every 1–3 minutes up to a maximum dose more susceptible to adverse
of 250 mg. The elderly are more susceptible to effects. Increased toxicity with
adverse effects of barbiturates. Also, duration of other CNS depressants.
action is unpredictable due to variable kinetics
in this population.
Methohexital Barbiturate anesthetic Adults 16–64 years of age: Onset: Hypotension, myocardial Ultra-short acting barbiturate
(Brevital) (Depresses CNS activity by 1 mg/kg to a maximum of 2 mg/kg 1–3 min depression, CNS and respiratory useful for short procedures.
binding to the barbiturate Elderly (> 65): Duration of depression, nausea, vomiting, No analgesic effects. Inactive,
site on GABA-receptor 0.5–1 mg/kg up to a maximum of 2 mg/kg. Action: diarrihea, cramping, laryngospasm debilitated, and elderly may be
complex, enhancing GABA The elderly are more susceptible to adverse 10–15 min more susceptible to adverse
activity) effects of barbiturates. effects. Increased toxicity with
other CNS depressants.
Nitrous Oxide General CNS depressant Adults: Onset: 2–5 Prolonged use may produce Inhaled gas used for dental
(May act similarly as For sedation and analgesia, concentrations of minutes bone-marrow suppression and/ and other short procedures
inhalant general anesthetics 25–50% nitrous oxide with oxygen, inhaled or neurologic dysfunction. The which induces sedation and
by mildly stabilizing axonal through the nose via a nasal mask. developing fetus and patients with mild analgesia. Should not be
membranes: May also act Avoid in pregnant patients, especially during vitamin B12 and other nutritional administered without oxygen.
on opioid receptors to cause the first two trimesters, due to increased risk of deficiencies are at increased risk Should not be administered to
mild analgesia) spontaneous abortion and teratogenicity. of developing neurologic disease patients after eating a meal.
with exposure to nitrous oxide.
Chapter 22 Conscious Sedation
257
258 Section 5 Behavioral Pedodontics

lift or jaw thrust, persistent airway obstruction may

require the use of airway adjuncts, suspend further drug
administration. cyanosis and oxygen desaturation.

mask positive ventilation and even intubation. and variable respiratory acidosis.

pulmonary hypertension and pulmonary edema may

Anaphylaxis and Anaphylactoid Reactions
occur.

and are characterized by wheezing, dyspnea, syncope,

Nausea and Vomiting
hypotension, and upper airway obstruction.

hypotension, tachycardia, bradycardia and aspiration.

Prompt recognition of the clinical situation and stopping
the administration of the suspected offending drug, hospital admission.

with endotracheal intubation, Prompt use of fluids and (younger patient more susceptible), Female gender,
history of postoperative emesis, Presence of hypoglycemia,
pain, hypotension, or hypoxia.
Aspiration
causes of hypoglycemia, pain, hypoxia, or hypotension,

recent oral intake, diabetes, pregnancy, obesity, altered

consciousness.

POINTS TO REMEMBER

independently and continuously maintain an airway and respond appropriately to physical stimulation or verbal command
and that is produced by a pharmacological or nonpharmacological method or a combination thereof.

treatment, enhance communication and patient cooperation, raise the pain reaction threshold, aid in treatment of the
mentally/physically disabled or medically compromised patient.

fearful, highly anxious or obstreperous patient, a patient whose gag reflex interferes with dental care, a patient for whom
profound local anesthesia cannot be obtained.

2O and 70 percent O2.

to 5 minutes.

effective.

management modalities have proved to be unsuccessful.

 Chapter 22 Conscious Sedation 259

QUESTIONNAIRE

9. Describe Midazolam sedation.

11. Describe the drugs used for conscious sedation.

REFERENCES

5. American Academy of Pediatric Dentistry. Guideline on use of nitrous oxide for pediatric dental patients.

76.

11. American Academy of Pediatric Dentistry. Policy on minimizing occupational health hazards associated with nitrous oxide. Pediatr

dental patients: an in vivo

of anesthesia in pediatric patients. Anesthesiology. 1992;76:109.

Anesth Analg. 1997;85:1207–13.

BIBLIOGRAPHY