Frequently Asked Questions

It is highly recommended to have an oxygen cylinder available in the surgery room where intravenous sedation (IVS) is being administered. Supplemental oxygen may be required if the patient struggles to maintain adequate oxygen saturation levels, especially in the case of a medical emergency. Delays in providing oxygen can put the patient at unnecessary risk. 

There are drug denaturing pots or kits available specifically for the disposal of unused midazolam.

Unused midazolam should be denatured in accordance with local controlled drugs (CD) procedures and documented appropriately in the CD register. 

Ideally midazolam should be disposed of in a drug denaturing pot or otherwise emptied onto a tissue and disposed in the clinical waste bin.

Do not leave midazolam in a syringe / open ampoule in the sharps bin as, in theory, this could be recovered and misused.

All disposal must comply with local controlled drugs (CD) procedures and be appropriately recorded.

There is no strict upper age limit for intravenous sedation. The eligibility largely depends on an individual's overall health assessment. Important factors to consider include the ASA (American Society of Anesthesiologists) grade, airway assessment, any existing comorbidities, current medications, and the availability of an escort. For older patients, it is advisable to administer midazolam more slowly and in smaller increments—typically, half the usual dose over double the time.

It would be advisable to have 2 oxygen cylinders, one for medical emergencies and one for sedation purposes. The sedation cylinder may be used as an adjunct during sedation if the patient's oxygen saturation is falling or is not maintained or for any emergency situation. This cylinder should be kept in the surgery where sedations are performed and be readily available.

Having 2 cylinders will always ensure there is at least one full cylinder onsite at all times. 

Things to consider are the layout of the practice, where oxygen is kept, and informing all team members of this.

Before providing sedation at other practices, consider creating a checklist covering: - Practice policies on sedation - Appropriateness of the environment in line with IACSD guidance - Availability of medical emergency drugs and equipment - Secure transport and logging of sedation drugs - Clinical record-keeping at both the practice and your end. Ensure the pre-sedation assessment is conducted in person before the day of sedation and clarify the consent process. While the dentist and nurse do not require specific sedation training, they should be ILS trained. Keep your sedation CPD and competencies up to date in accordance with IACSD guidance. 

During recovery, the patient must be supervised by a trained member of the dental team. It is acceptable for the patient to be in the recovery room with an escort while the trained team member checks on them periodically. It’s advisable to inform the escort of the trained member's location in case of emergency. Each case should be assessed individually; a patient showing more sedation may need closer monitoring than one who is nearly recovered.

Regarding your query about IV sedation with midazolam for an epileptic patient classified as ASA grade 2: this is a safe option. Administering Midazolam is wise, as the stress and anxiety of a dental procedure can trigger seizures. 

Midazolam supplied for intravenous sedation is typically provided in glass ampoules, and the recommended practice when drawing up any medication from a glass ampoule is to use a filter needle or filter straw. This is because opening a glass ampoule can occasionally introduce microscopic glass particles, and the filter helps prevent these from being drawn into the syringe.
 
If a filter needle is temporarily unavailable (for example due to supply issues), it is not uncommon in clinical practice for clinicians to draw up midazolam using a standard drawing-up needle, taking care to open the ampoule cleanly and avoid drawing up any visible particles.

However, the best practice remains to use a filter needle whenever possible, and practices should ensure that these are restocked as soon as feasible.
As always, medications should be drawn up using aseptic technique, labelled appropriately, and administered according to local protocols and current sedation guidance

IV sedation with midazolam is a good technique for patients with cerebral palsy and other movement disorders as it can reduce or eliminate unwanted movement, allowing dental treatment to be carried out safely. If the movement is severe, you will need to discuss manual support / clinical holding with the patient to cannulate. Inhalation sedation with nitrous oxide can also work well.

Exercise caution with the airway. Some, but not all, patients with cerebral palsy have involvement of the muscles used in swallowing. Obviously when doing procedures involving water in a sedated patient, in whom you have induced further muscle relaxation, aspiration / choking can pose a risk and be unpleasant for the patient. Therefore, good aspiration is vital and also using a 45-degree dental chair position. Similarly, the respiratory system can be compromised and baseline saturation at the assessment visit is essential. A good tip is to assess the viscosity of the saliva, clarity of speech (control of oral musculature) and ability to drink water without coughing at the assessment visit.

Having said that, a lot of patients have no problems with their airway and the cerebral palsy is mild. For these patients midazolam IV sedation works well and enables patients to have ‘normal’ dentistry. There is a large spectrum of associated disability with this condition and the patient is likely to know their cerebral palsy well.

Here is link to an article which might be useful: https://www.dental-update.co.uk/content/special-care-dentistry/sedation-for-patients-with-movement-disorders

 The dosage of sedation drugs (IV or inhalation sedation) is not correlated in any way with a patient's height, weight, or BMI. This is why we have to titrate the drugs to the conscious sedation endpoint.
The only time we might measure a patient's height is if there is some doubt that they have developed normally for their age. Abnormal development, not just height, might mean some sedation techniques might be unsuitable in a primary care setting.

This is an interesting question, often discussed. Although the BNF states an adult maximum of 7.5 mg per episode of treatment, midazolam as a conscious sedation agent is titrated to the patient’s response and experience shows that this may be a too-low total dose in some patients. Titration ensures neither under-sedation nor over-sedation and guards against negative outcomes either way. The BNF also says an adult initial 2 – 2.5 mg as an initial dose. Individually this may be too high in some patients. So a titrated dose is paramount but may exceed the BNF guidance. There is also a variation for the young and elderly. The scientific literature supports the above.

SAAD considers that dental sedationists must carry out a thorough clinical assessment of the patient including a full contemporaneous medical history including responses to previous sedatives. This should be signed and dated by the patient to validate full disclosure on the day of the procedure.

The length of the procedure, the peak effect of the sedative drug and its half-life should also be considered. This will all have an impact on the route and drugs used for sedation for an individual patient and the titration regime. It is for this reason that SAAD does not teach an absolute minimum or maximum dose. The amount and titration regime of midazolam given should be a clinical decision made by a sedationist with the appropriate knowledge, skills training, and experience.

In primary care setting for patients under 16 years of age: 

• Inhalation sedation (nitrous oxide/oxygen) is preferred technique
• Single agent midazolam IV sedation may be considered in carefully selected cases
• Patients must be ASA I or II
• No complex dental or medical needs
• Appropriate consent and chaperone procedures must be followed 

Clinicians must ensure they are trained and competent in accordance with IACSD Guidance (2020) for paediatric patients 

Please refer to page 26 of the IACSD Guidance (2020). Essentially,  inhalation sedation or single agent midazolam sedation only, for ASA I/II and no complex dental or medical needs.   

There is no evidence that IV midazolam will trigger a desire to start using drugs again

If flumazenil is used to manage acute respiratory depression / apnoea which could not be resolved by asking the patient to take deep breaths / opening the airway / IPPV then this should be logged as a clinical incident.

Using flumazenil electively to improve the quality of recovery (e.g. making travelling home safer) is not a clinical incident but you should have appropriate criteria for its use and keep records. Dr. Christopher Dickinson published a paper some years ago explaining what is done at Guy's Hospital regarding this.

However, the use of flumazenil to increase throughput of patients or just to speed recovery so staff people can go home on time is unacceptable! 

Thank you for your enquiry. SAAD do not recommend any particular machine but do advise the pulse oximeter is not one of the wireless finger probe battery devices that can be purchased cheaply online. We would advise using a medical equipment supplier.
Personally, I use a Dinamap/Mindray similar to what would be used in hospitals to take BP, pulse and O2. These can be quite expensive so a separate BP machine and separate pulse oximeter maybe preferable.

Key features that are useful:

• • Automated blood pressure readings at set time intervals
  • Audible pulse tone
  • Alarms for pulse, blood pressure and oxygen saturations outside of normal ranges.