Sedation in dentistry and out-patient maxillofacial surgery. Theory and practice

Abstract

In recent decades, the use of medical procedural sedation in outpatient settings has gained considerable popularity due to the expansion of treatment options for the doctor and increased comfort for the patient. Moderate medical sedation allows patients to better tolerate medical and diagnostic manipulations, avoid operative stress and associated anxiety, fear and pain. This is of great importance to a wide range of patients. For example, patients with accompanying arterial hypertension, with heart rhythm disturbances and myocardial ischemia, provided that sedation is carried out during outpatient interventions, avoid the possibility of decompensation of cardiac pathology. For children, the elderly, or patients with special needs, any hospitalization associated with forced separation from family is associated with psychological trauma. Therefore, it is important to carry out medical and diagnostic procedures under sedation in outpatient settings that are small in terms of trauma and duration. The advantages of ambulatory anesthesiology include economic expediency, convenience for the patient, reduction of the risk of thrombotic complications and hospital infection, and increased efficiency of hospital beds. Modern anesthesiology has a rich arsenal of techniques and drugs for anesthetic support of outpatient operations, but the issues of finding the optimal scheme for sedation, assessing its adequacy, and means of monitoring the patient's condition remain relevant and require in-depth study. This review presents modern recommendations for procedural sedation in adults and children in outpatient settings. The definitions of sedation, psychoemotional comfort and discomfort are thoroughly described and introduced. A special emphasis is put on pathophysiology of psychoemotional discomfort and peri-operative stress. According to modern data, the objectives to be achieved by an anesthesiologist have been reviewed: provision of psychoemotional inhibition (as a basis of comfort staying in a dental chair), but not depression of consciousness as it used to be before. With much detail it analyzes complication occurring during anesthesia; their correlations with age. concurrent conditions, anesthetic agent and doctor’s professional level are highlighted. The article presents a clinical picture of sedation depending on the depression of consciousness, respiration, and hemodynamics (ADA and ASA, 2016). It depicts thoroughly the state of minimal sedation (anxiolysis), moderate sedation (awake sedation), deep sedation and general anesthesia. Special attention is paid to the provision of patient’s safety related to supporting airway patency and hemodynamics. The article presents methods of sedation from the position of modern global data and personal experience of authors. Methods to medication administration are mentioned: enteral, parenteral, including intra-nasal which is fairly popular of late. Special attention is paid to specific problems of sedation, presence of motion activity, psychoemotional agitation, compulsive coughing. Potential causes of these events are described, in particular, correlation between psychoemotional agitation with dysregulation of GABA-ergic and dopaminergic systems. Current data on the intra-operative monitoring are presented, as an important component of the patient’s safety during sedation. Additionally to Harvard Standard, it is recommended to use capnograpy and monitoring of sedation depth through bispectral index.