Introduction to Pain and Anxiety Control

7/26/2019 Introduction to Pain and Anxiety Control

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Kyle J. Kramer, DDS, MS

7/12/11


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! Inhalation Minimal Sedation! 14 hours of instruction

! Clinical competency

!

Enteral and/or Combination Inhalation-EnteralMinimal Sedation! Current BLS

! 16 hours of instruction


!

Experience compromised airway management

Note: Guidelines do not pertain to sedation of pediatricpatients


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!

Moderate Enteral Sedation! 24 hours of instruction

! 10 adult patient case experiences*

"

Enteral" Enteral-Nitrous Oxide


! Management of compromised airway

Note: Guidelines do not pertain to sedation ofpediatric patients


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!

Moderate Parenteral (IV) Sedation

! 60 hours of instruction

! 20 adult patient case experiences

!

Clinical competency

! Management of compromised airway

Note: Guidelines do not pertain to sedation ofpediatric patients


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! Successful completion fulfills didactic requirements! 14 hours ACLS

! 10 classes over next 5 weeks" Lectures

"

Midterm"

8/1 to 8/8

" Final exam"

8/15 to 8/22

" Labs"

IV placement/IM injections"

Preoperative evaluation and ASA Monitors

!

2 sessions"

Airway Lab (2 half-days w/ Dr. Kramer in OMS clinic)

! Competency Evaluation" Case review and presentation/oral evaluation


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!

Define and describe pain, anxiety and fear

!

Review historical, philosophical andpsychological aspects of anxiety and pain

control!

Define consciousness and levels ofsedation! Minimal sedation

!

Moderate sedation

! Deep sedation

! General anesthesia


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! 40% of population doesnt receive routinedental care! Apprehension given for most common reason

! Mild apprehension of dental treatment! Very common: 75% of population

!

Severe anxiety leading to avoidance oftreatment! Less common: 6-20% of population


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! In the US an estimated6-14% of thepopulation avoidsdental care due to fear

of dentistry! 14-34 million

! Anxiety and fearremain significant

roadblocks to patientcare! Despite advances in pain

control


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n = 400


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Problems

1. Poor oral health

2.

Patients are fearful of dentaltreatment

3.

Inadequate access to care1. Few dental sedationists

compared to number of patients2. Remains a problem despite

improvements


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Fear continues to besignificant barrier to

patient care! Public Speaking 27%! Dentists 21%! Heights 20%


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Our Goals

! Improve access to care!

Improve patient care andcomfort

!

Our professional obligation todo better


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Methods of improving access tocare

!

Non-pharmacologic! Verbal guidance and reassurance! Distraction (listen to music, watch a

movie)!

Hypnosis

!

Pharmacologic! Anxiolysis! Minimal sedation! Moderate sedation! Deep sedation! General anesthesia


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!

An unpleasant sensory and emotionalexperience associated with actual or

potential tissue damage, or described in

terms of such damage InternationalAssociation for the Study of Pain


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!

Neural processes of encoding andprocessing noxious stimuli

! Afferent activity blocked by local anesthetics

!

Autonomic process

! Consciousness not required

!

Intraoperative and postoperative

importance! An absolute must for all types of sedation


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!

Activation of the sympathetic nervoussystem

! Release of epinephrine from adrenal glands

!

Fight or flight response

! Emotional responses

" Crying, scared, etc.

!

Physical responses" Tachycardia, hyperventilation


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! Short-livedphenomenon,disappearingwhen theexternal danger orthreat passes

! Autonomic responsedependentof thethreat! If the threat (a spider) is

present

activation of thefear response

! Once spider is gone, thefear response resolves


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1.

Fear of pain*

Is it going to hurt?

2.

Fear of the unknown

3.

Fear of helplessness and dependency

4. Fear of bodily change and mutilation

5.

Fear of death


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! Arise from many

sources

! Past traumatic

experiences! Observation of others

! Concerns or worries

! Exposure to anecdotal

stories


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1.

Fear of pain*

Is it going to hurt?

2.

Fear of the unknown

3.

Fear of helplessness and dependency

4. Fear of bodily change and mutilation

5.

Fear of death


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!

Both groups had

similar fears

!

Dentists can

eliminate sometriggers

! What do patients

care about?

! No pain!

! Work quality???


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! A specific unpleasurable state oftension which indicates thepresence of some danger to theorganism Weiss and English

! Autonomic response

independentof the threat! Memory of the spider -> activation

of fear response

! Can arise with anticipation of thetriggering event

! Usually a learned response

! Can lower pain thresholdsignificantly! Innocuous stimuli -> interpreted as

pain


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! Several types of anxiety Generalized anxiety disorder

Panic disorder

Obsessive-compulsive disorder (OCD) Social anxiety disorder

Specific phobias (arachnophobia)

Post-traumatic stress disorder (PTSD)

Situational stress anxiety****

Note: May often have additional diagnosis ofdepression


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General Anxiety Situational Anxiety

!

Mood disorder! Anxious but dont know why

! Biochemical changes in theCNS

! Treatment modalities

!

Pharmacotherapeutics

" Mood stabilizers

" Antidepressants

" Anxiolytics

! May require larger doses

!

Anxious secondary to anevent (dental visit)

! Treatment modalities

! Non-pharmacotherapeutics

" Iatrosedation

"

Hypnosis! Pharmacotherapeutics

" Nitrous oxide

" Anxiolytics

! May respond to smaller

doses


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Similarities Differences

!

Autonomic response! Physical

! Emotional

! Learned response?

! Requires consciousness

!

Threat present/not present

! Learned response?


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!

Goals of Pharmacologic Management

! Induce an altered state of consciousness

" Relative analgesia

"

Co-medication

" Twilight sleep

" Chemamnesia

! Reduce/eliminate stress and anxiety

Sedation


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!

Analgesia:

! The diminution or elimination of pain

!

Local anesthesia:

! Elimination of sensation, especially pain, in one

part of the body

" Predictable and reversible

! Via topical application or regional injection ofa drug


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Minimal Sedation (Anxiolysis, Stress reduction):

! Minimally depressed level of consciousness

" Modest impairment of cognitive function and

coordination" Respond normally to tactile stimulation and verbal

command

! Independently and continuously maintain own

airway" Airway reflexes intact

! NOcardiovascular or respiratory depression


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Moderate Sedation

! Depressed level of consciousness

" Respond purposefully to verbal commands, either

alone or with light tactile stimulation! Nointerventions are needed to maintain a

patent airway

" Spontaneous ventilation is adequate

"

Airway reflex impairment possible! Cardiovascular function is usually maintained


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Deep Sedation

! Depressed level of consciousness" Cannot be aroused easily

"

Dorespond purposefully to repeated or painfulstimulation

! Ability to maintain patent airway may becompromised" May require airway support

"

Airway reflexes impaired" Spontaneous ventilation may be inadequate

! Cardiovascular function is usually maintained


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General Anesthesia

! Unconscious

" Not arousable, not even to painful stimulation

!

Respiratory function is often impaired" Airway support/patency may be required

" Hypopnea/apnea

" Positive pressure ventilation

"

Airway reflexes impaired! Cardiovascular function may be impaired


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! Best viewed as a continuum

! No defined step to reach a setlevel

!

Ability and speed to move alongthe continuum varies greatly

!"#$%&"'$

)#%"#$%&"'$

*+,-

How high is this plane?

How far away is it?

Is it high enough to fly over orunder the sun?


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Stage I: Induction! Analgesia

! Conscious sedation

Stage II: Excitement!

UnconsciousStage III: SurgicalAnesthesia

! Planes 1-4

Stage IV: MedullaryParalysis

!

Respiratory arrest

! Cardiovascularcollapse


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Dionne, R Drug Interactions and Adverse Effects In: Anesthesia and Sedation in the Dental

OfficeDionne R and Laskin D (eds). Elsevier 1986 p. 63


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! Levels of sedation! What is the main goal

of the sedation?! What physiologic signs

are we looking for?

! Minimal sedation! Conscious sedation! Anxiolysis

! Moderate sedation!

Deep sedation!

General anesthesia

???


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!

History of dental anxiety, fear or phobia! Phobic patient

!

Patient management issues! Mentally disability" Alzheimers dementia

! Physically disability

"

Cerebral palsy" Parkinsons disease

! Precooperative children


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! Invasive or extensive procedures! Full mouth extraction

! Mandibular resection and reconstruction

! Physically compromised patients! Ischemic heart disease

! Stress-induced asthma

Need to match the level of sedation with thepatient and the surgical procedure!!!


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Class Description

I Normal, healthy patient

II Mild systemic disease

III Severe systemic disease that limits activity but is notincapacitating

IV Incapacitating systemic disease that is a constant threat

to lifeV Moribund patient not expected to survive 24 hours with

or without operation

VI Clinically dead patient kept alive for organ donation

E Emergency operation*


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Enteral Parenteral!

Drug is absorbed throughthe GI tract or oral mucosa

! Subject to first passmetabolism

! Oral

!

Rectal

! Sublingual*

!

Drug bypasses the GI tract!

NOT subject to first pass

metabolism

! Intravenous

! Intramuscular

!

Intranasal

! Submucosal

! Subcutaneous

! Inhalational


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! Route DOES NOT determine the depth of sedation

! Any route has the potential to induce any degree of sedation or anesthesia*

! Route of administration MUST comply with the needs of the surgery and thepatient


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Providers MUST:

1. Be able to identify thedepth of sedation

2. Be able to rescue patientswho become sedateddeeper than the intendedlevel- Reversal of sedation

3. Be able to manage

sequela that arise due tothe unintended depth ofsedation- Airway support

- Cardiovascular support


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! 3 As! Anxiolysis! Amnesia! Analgesia

!

Cardiovascular and respiratory stability! Quickly alter depth

! Rapid, comfortable induction! Rapid, clean emergence

!

Postoperative analgesia! No PONV! Inexpensive


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!

There is no magic bullet

!

Use of balanced anesthetic

! Combination of techniques

!

Benefit/risk of each drug

! Example: Benzo + opioid + LA

! The right combination is the one that

works


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! No additional licensing for the following:

! Inhalation Minimal Sedation" Nitrous oxide + Oxygen

! Enteral and/or Combination Inhalation-EnteralMinimal Sedation

! Moderate Enteral Sedation

! However, this is likely to change in the nearfuture


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! Great for anxiolysis

! Includes supplemental

oxygen

!

Easily reversible! If pt is breathing!!!

! Can be titrated, even

with oral sedation

! Very safe

!

Caution"

Significant additive sedationand muscle relaxation

" AIRWAY, AIRWAY, AIRWAY!!!!!


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Light Parenteral Conscious Sedation Deep sedation

! Minimally depressed level ofconsciousness

! Maintain own airway

! Respond to stimulation

! THIS IS OUR GOAL!!! Awake!

Breathing! Calm! Responsive! Relaxed

! Depressed consciousness

! Partial loss of protective

reflexes

! Inability to continually

maintain airway

!

Unresponsive to

stimulation


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!

Applicant must meet one of the followingcriteria:

!

(1) Graduation from an approved dentalschool which included training in conscious

sedation techniques at the predoctoral level

!

(2) Completion of an intensive postdoctoraltraining program in the use of light parenteral

conscious sedation


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! Satisfactory evidence of completion ofeducational and training requirements means thefollowing:

!

(1) Certificate of completion of the educational ortraining program

! (2) Official transcript from a board approved dentalschool which clearly designates completion of theeducation or training.

! (3) Certificate of completion of a continuingeducation program


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Requirements:

!

Valid Indiana dental license

!

Valid LPCS permit

!

Provide training certificate

! Equipment affidavit

! ACLS certified


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Requirements:

!

Valid Indiana dental license

!

Valid GA/DS permit

!

Provide training program certificate

" Dental Anesthesiology

" Oral and Maxillofacial Surgery

!

Equipment affidavit! ACLS certified

Introduction to Pain and Anxiety Control

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