In a recent tutorial / surgeons meeting with my group at Alfreton Primary Care Centre when had a session on sedation and sedation updates.
We kept a very strict audit of sedation including the amount of cannula attempts we use and the amount of drug we give, on average, to each individual patient.
It would be good to enter into a wider discussion about this because I feel patients in dental practice are grossly over sedated. We provide sedations for genuinely frightened patients who are undergoing, sometimes complex procedures, in oral surgery including third molar removal or dental clearances.
Our average dose of sedation at the practice is 4.5mg - this is extremely low compared to other practitioners I speak to but actually it is due to the technique. Patients generally don’t need a lot of drug if the technique is appropriate.
In general, the recognised technique is to give 2mg of sedation followed by 1mg after a minute and 1mg every subsequent minute from there but this doesn’t seem to match up it the pharmacology of Midazolam, where the 2mg dose can take 10 - 12 minutes to reach its maximum effect. Therefore a patient could have 10mg in their system already before the initial dose has actually shown its maximum effect. The procedure we prefer is to give a 2mg dose and wait 3 - 5 minutes to gauge the patients response, we find not infrequently that we don’t give ANY more sedation that this as patients response continues to deepen after 5 minutes and we can administer local anaesthetic and be on with the procedure before the patient begins to recover.
It maybe that we give 1 or 2mg further, often a 1mg more after local anaesthetic is administered as patients wake up a little bit at this stage but we find this procedure very successful and it limits the amount of drug the patients have to receive.
This also makes recovery from sedation much quicker as very rarely do our patients ever get over-sedated. It is infact a significant act for us to open a second vial of Midazolam now that they vials are 5mg in 5mls and this acts as a psychological barrier. We believe this is an excellent technique that we have been using for a considerable period of time.
What is everybody else doing?
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