In some cases, the patient’s unrest can be so severe that they experience heart palpitations, circulatory problems and sweating. According to estimates, between five and 10 per cent of British people suffer from dentist phobia. This makes it seem impossible for them to see a dentist. Those affected often are not aware that treatment can be performed under sedation or local anaesthetic, which means they will not feel any pain. At our London clinic, we know how best to look after phobic patients: we make sure that your memories of your dental appointment will be good ones. We will also make sure that you leave with a smile on your face, so it will be easier next time.
What does Conscious Sedation mean?
The phrase conscious sedation was coined by the American Dental Association, referring to a technique used to make patients comfortable during the operation. Conscious sedation is probably the fastest growing area in anaesthesia care, and has become a very effective and viable alternative to general anaesthesia for many surgical procedures, e.g., dental procedures, plastic and reconstructive surgery, dermatology, endoscopies, bronchoscopies, and liver and renal biopsies. You will come in on the day of surgery and leave the same day usually within one hour after the operation. In addition there is a significantly lower incidence of side effects with conscious sedation (including low incidence of nausea and vomiting, headaches, sore throats, muscle aches, and pain), and the cost for conscious sedation is much lower compared to general anaesthesia.
What is Conscious Sedation?
The aim of sedation is to make you comfortable, totally relaxed and safe during a procedure. Administration of the sedatives and analgesia results in your becoming drowsy and sleepy, pain-free, and probably amnesic such that you will have very little recollection of the procedure. Communication is possible if necessary during the operation because even though you are completely relaxed and unconcerned, you are not completey unconscious at any point in time. Your vital signs, e.g., blood pressure, breathing, pulse rate, etc. are monitored throughout the procedure to ensure your safety, and a sedationist will stay with you all the time. Conscious sedation is achieved with intravenous agents ( e.g. benzodiazepines, opiates, other sedative/anaesthetics) usually administered into a vein, and/or inhalation agents (e.g. nitrous oxide).
Recovery after sedation is much faster than with general anaesthesia. The same applies for the side effect profile, e.g., nausea and vomiting, headache, muscle pain and sore throat, which is much less than with general anaesthesia – in fact very few patients experience any side effects at all. For these reasons patient satisfaction is very high after conscious sedation – a recent survey of the experiences and satisfaction of patients who had sedation show that 99.5% of patients would take sedation again if they have a choice.
What are the different types of Sedation?
There are three different levels of sedation that are defined and recognized internationally. The three sedation levels recognized in the UK today include:
Minimal Sedation (or Anxiolysis): This is often referred to as changing the mood of the patient whereby the patient is calmed, responsive to verbal commands, and unconcerned about the procedure.
Moderate Sedation or Conscious Sedation: This is where the patient is more deeply sedated, becomes drowsy and sleepy (and may even sleep intermittently), is responsive to verbal commands, and calm.
Deep Sedation: At this level of sedation patients may become unconscious. This level is not allowed in the UK for sedation outside the operating room.
What is the difference between Sedation and Anaesthesia?
The main differences between conscious sedation and general anaesthesia is the level of consciousness, safety, side effects, use and cost.
Level of consciousness: With conscious sedation the patient is drowsy, comfortable, sleepy and relaxed, but remains conscious. Patients can be roused by verbal communication if necessary. With general anaesthesia the patient is completely unresponsive and cannot be roused by verbal communication.
Safety: With conscious sedation the required dose of drug is low and the patient is still in control of major reflex functions such as breathing. With general anaesthesia the higher doses of drugs renders the patient unconscious, who then loses these reflexes which must be, in turn, maintained artificially. Higher doses of drugs administered with general anaesthesia are associated with higher risks.
Side effects: Due to the lower dose of sedative/anaesthetics the frequency of side effects are minimal when compared to general anaesthesia, where the side effect profile is much more substantial.
Use: The conscious sedation drugs are given to relax you while the local anaesthetic durgs will take away the pain
Cost: The fact that the recovery period of sedation is much quicker than with general anaesthetia, combined with the fact that sedation does not require hospital settings, means that the cost of sedation is far lower than that for general anaesthesia. General anaesthesia can only be done inside a hospital in an operating theatre.
What is a Sedation Provider?
A sedation provider service is a dedicated team of sedation practitioners, nurse practitioners and/or nurses who provide sedation. The team concept is an extremely important part of safe sedation practice. There are two types of sedation-provider services:
The operator sedation practitioner: Here the surgeon administers the sedation and also performs the surgical procedure. Dedicated staff will be part of the team and help him/her to monitor the patient.
The dedicated sedation practitioner: Here a dedicated sedationist administers the sedation while the surgeon does the surgery. The sedation practitioner looks after the wellbeing of the patient from a sedation perspective, which allows the surgeon to focus on the operative procedure.
All sedation practice is closely regulated to the highest professional and ethical standards. All sedation team members and practitioners must have appropriate training in the administration of conscious sedation including monitoring, management, and care of the patient while under sedation. It is also mandatory that sedation practitioners attend regular training updates in knowledge and skills.
Is Conscious Sedation an option for all patients?
As with any anaesthetic, the suitability of conscious sedation is determined by the patient’s age, health and need, as well as by the procedure being performed. In the first instance, indications for conscious sedation include:
Procedures that do not need general anaesthetic such as:
- Routine investigations such as biopsies or endoscopies
- Routine interventions such as interventional cardiology or radiology
- Very anxious patients – sedation calms the patient and overcomes their fear and anxiety
- Patients who have had a previous traumatic experience – sedation makes it possible to deal with post-traumatic stress of the patient relating to medical or dental procedures
- Uncomfortable procedures – sedation relaxes, dissociates and helps comfort the patient
- More invasive, complex and prolonged procedures – sedation ensures the patient can remain still yet comfortable for long periods of time
- Procedures in adults that may not be particularly painful, but require them to be very still during the surgery
- From a medical perspective, adults who are healthy or have controlled medical conditions (e.g., hypertension, diabetes, asthma … all adequately controlled), qualify for sedation. Patients with significant or uncontrolled medical conditions (e.g., severe heart disease, morbid obesity, etc.) need to be assessed on a case-by-case basis as to their suitability for sedation, where it may be an option to perform the procedure within a hospital setting.
Conscious sedation should thus always be evaluated with respect to other available options, including local anaesthesia and/or regional anaesthesia, local anaesthesia with behavioural management techniques, general anaesthesia and conscious sedation itself. Patients should always be involved in the decision-making after receiving an explanation of the available options.
Can you eat before Sedation?
All patients will receive pre-and post-operative instructions.
The general guidelines are as follows. See that you follow these guidelines, otherwise your operation may have to be cancelled:
No solid food for six (6) hours prior to the procedure
All patients may have clear liquids until two (2) hours before the procedure
In the unlikely event that you may feel sick after your treatment, it is safer for you not to eat anything for six hours before your appointment. However, you may drink water up to two hours before your appointment. Please continue to take your regular medication at the usual times with a little water.
If you suffer from diabetes or have other dietary problems please discuss this with your sedationist before your appointment. Diabetic patients will get special instructions as far as food intake is concerned.
What is Conscious Sedation like?
Even though you are not completely asleep. At the beginning you will start to feel drowsy and become relaxed very quickly. The sedative drugs combined with analgesics and local anaesthesia ensures that you will have no pain during the operation. The drugs will also contribute towards a pain-free period after the operation.
How long does it take to recover from Sedation?
The recovery time depends on the drugs used, the patient’s individual response to the drugs, and the time spent under sedation. The drugs and doses that are used for sedation have a rapid onset and offset. After the administration of the sedative drugs is stopped, recovery is swift and in most cases less than about 30 minutes, which is the time that you will need to remain at the clinic before being allowed to go home with your escort. The sedation practitioner will carefully monitor you to ensure that you are fit for discharge. Thereafter you may remain drowsy for a few hours, and will be given specific written and verbal instructions on what to do.
Are there any side effects to Sedation?
As with any medication, the use of sedative anaesthetic agents can result in side effects. However, the incidence of side effects with sedation are very rare and include unintended loss of consciousness, drowsiness, dizziness, shivering (4%), headaches (4%), and post-sedation nausea & vomiting (0.7%).
How should I spend my time at home recovering after the operation?
Elimination of the sedative agents from your body can take up to 24 hours. It is important during this time to rest and recover from the procedure. Therefore, however well you may feel, during that time you should NOT:
- Drive a vehicle (insurance will be void)
- Cook or use electrical implements
- Operate any machinery
- Sign important documents, cheques, etc.
- Look after children
- Ride a bicycle, etc.
- Make important decisions, etc.
- Use alcohol, sleeping tablets, tobacco, abuse drugs
- Perform other complicated tasks or responsibilities
You will not be allowed to drive yourself home, and you will not be able to leave the clinic or facility if there is not a responsible adult who can drive you home and oversee your post-operative recovery period. You should remain in the company of a responsible adult for 12 hours following the procedure.
Does my medical insurance pay for the Sedation?
You should contact your medical insurance before the operation to get authorization and information. Medical insurance is increasingly interested in sedation services because of the many advantages including effectiveness, safety, cost savings, and convenience.
Who is qualified to provide Sedation?
Sedation practitioners have all completed undergraduate medical studies and appropriate postgraduate training and qualification in anaesthetics and/or sedation. It is clear that conscious sedation can only be done by those trained AND experienced in how to evaluate and assess the patient, administer the sedative drugs, monitor the patient, and deal with any side effects or situations that may arise. All international and UK guidelines require that conscious sedation practitioners must be appropriately trained and experienced. In addition, practitioners must undergo thorough postgraduate training and appraisals to ensure fitness to practice. There are several institutions in the UK that offer training in conscious sedation.
According to the American Society of Anaesthesiologists Task Force on Sedation and Analgesia, sedation can be provided by anaesthesiologists as well as non-anaesthesiologists who are appropriately qualified. There are thus three main groups of sedation providers:
Professional sedation practitioners are medically qualified practitioners with extensive postgraduate certification (Diploma, Masters qualification etc, training and experience in conscious sedation. They are usually full time in sedation practice in surgeries, clinics, hospitals, and often travel between facilities to administer sedations.
Operator-sedationists are practitioners from different sub-specialties (e.g., dentists, radiologists, gastro-enterologists) who, in addition to performing the procedure, also administer the sedation.
Anaesthetists are usually qualified anaesthetists/consultants who also administer sedation inside hospitals. They do not do sedation full time, and represent a smaller group than those above.
Where can Conscious Sedation be administered?
Conscious sedation can be done in hospitals as well as outside a hospital or operating theatre setting, including:
- Dental or medical surgeries or clinics
- Approved facilities with necessary monitoring and emergency equipment and appropriately trained staff
Conscious sedation should only be performed in an environment where the facilities, personnel, equipment and drugs required to administer, monitor and manage any complication are immediately available and provided with the same level of care as in the hospital environment.
Am I allowed to take my herbal drugs before sedation?
Many patients are on herbal drugs for different reasons. It is very rare that they would interfere or cause serious complications with conscious sedation. However, it is important that the sedation practitioner knows which herbal medication you may be taking. Herbal drugs can influence sedation by interacting with the sedative drugs. Some herbal drugs have a sedative effect and can potentiate the effect of the sedative drugs; some interfere in other ways, such as increasing the bleeding tendency. So it is therefore obviously important that you let your sedationist know if you are taking herbal medications, and if possible consider stopping them a week or two before the procedure.
Are there other links where I can find more information on Sedation?
What are my options as far as my procedure is concerned?
You may choose:
- Not to have the treatment
- Have the treatment with local anaesthesia only
- Have the treatment under conscious sedation and local anaesthesia at the surgery
- Have general anaesthesia in a hospital environment
Advantages of Conscious Sedation?
The following list will give you a brief overview of the advantages with sedation:
- Low dose of sedation. Therefore, you may still have control over major reflex functions and have lower risk of having side effects at all.
- Verbal communication is still possible during medical intervention.
- No pain during the operation and afterwards.
Risks of Conscious Sedation?
Very rarely you may experience:
- Discomfort or bruising at the site of injection.
- Vein irritation (phlebitis), which can last a week and can be painful. This rarely happens when an elbow vein is used.
- Allergic reaction to any of the drugs used. Allergic reactions to the sedative drugs are extremely rare. Nausea and vomiting, although very uncommon, may occur.
Conscious sedation is a very safe procedure; however, the very rare complications should be mentioned: depressed respiration (slowing or stopped breathing), brain damage, stroke, heart attack or even a fatal outcome. The information that you give us on the attached medical history form will assist us when deciding whether you might be at risk to any known complications. Your sedationist is highly experienced in avoiding complications and is trained to deal with unexpected problems.
If I am conscious during the procedure why shall I not remember what happened afterwards?
Conscious sedation induces a state of deep relaxation. In over 90% of people the drugs used for conscious sedation produce either partial or full memory loss (amnesia) for the period of time when the drug first kicks in until it wears off. As a result, time will appear to pass very quickly. Consequently, people who remember nothing at all frequently report that they were “asleep” during the procedure.
Local anaesthetics don’t work well on me. Will Conscious Sedation help?
The surgeon can combine local anesthesia with sedation due to the fact that under sedation your tolerance to pain is much higher. Therefore the surgeon is able to use even more local anaesthetic and has more options in the various techniques of administering local anaesthesia. You will not be in pain under conscious sedation.
Will the Sedationist be present all the time?
Yes, the sedationist will be by your side all the time as the sedation drugs are administered continuously throughout the surgery. Additionally, your pulse, oxygen levels and blood pressure are constantly monitored and recorded to ensure your wellbeing.
What drugs are used for Conscious Sedation?
The most commonly used drug for conscious sedation is Midazolam, which belongs to the same family of drugs as Valium. However, in order to make the injections in the mouth almost painless and also to produce a better quality of sedation your sedationist may choose to add an opiate and/or Propofol or other drugs in controlled and titrated doses. Propofol allows for a much faster recovery but needs a dedicated trained sedationist to be present throughout the procedure.
Will someone need to accompany me? Driving after sedation?
You should not drive after sedation on account of the fact that you still may have sedative affects due to the medication. To comply with guidelines and for your own safety we must insist that you have a responsible adult to take you home after your appointment. In the event that you have no escort on the day of the sedation, your appointment may be cancelled and you will be charged in full. If you have no one to take you home we can arrange for a nurse to escort you home and stay with you. This will be at an additional cost and must be pre-arranged and pre-paid at least seven days prior to the appointment.
How long does conscious sedation last?
The length of your appointment will depend upon the procedure. There will be a recovery period of 20 – 30 minutes before you are discharged into the care of your escort. The sedative effect of the drugs will gradually wear off during the course of the day. Most patients are well enough to return to their normal activities within 24 hours depending on the nature of their work.
What types of procedures and patients are suitable for sedation?
Conscious sedation is preferred for a number of instances as outlined below:
- Removal of wisdom teeth
- Full mouth rehabilitations
- Fixed teeth in a day
- Large bone augmentations
- Placement of implants
Why am I having sedation?
Conscious sedation is clearly useful for patients who have a fear or anxiety about having minor surgical or dental treatment. Sometimes, the dentist or surgeon may request the sedation in order to make the treatment more comfortable for you or to create the optimal working conditions. In dentistry CS is particularly useful for patients with a strong gag reflex, small mouth opening or those individuals with a low tolerance to pain. It is also well suited for patients who fear the administration of local anaesthetic injections.
Does medication that I am taking interfere with the Sedation?
Whatever medication you may be taking – it is advisable to bring it to the surgery on the day of the operation to show to the sedation practitioner.
It is imperative that you advise the sedation practitioner of all the medication you are taking so that this can be factored into your assessment and administration of the sedation. You should continue to take your medications as usual, unless advised otherwise by the sedationist.
Antihypertensive (high blood pressure) medications: continue taking these as usual.
Asthma medications: continue taking these as usual and bring your inhalers with you.
Diabetes medications: it is important that the sedation practitioner gives you guidance here since it may be that you should have a meal, and not take oral anti-diabetic drugs the morning of the operation. You are encouraged to monitor your blood glucose levels before the sedation, and bring these with you to the surgery.
Antidepressants: an increasing number of patients are nowadays on antidepressants not only for the treatment of depression, but also to treat pain. It is of utmost importance that you inform the sedation practitioner of any antidepressants you may be taking, since certain classes of antidepressants can interact with the sedative agents, and it may be required that you stop these for a few days prior to the procedure.