# Management of anxiety during surgery  Management of anxiety during surgery Clinical laboratory photograph showing test tubes with yellow liquid and a pipette dispensing fluid. Includes chemical structure diagrams in the background. Context indicates this image is used to illustrate the topic 'Management of anxiety during surgery'. # Learning Outcomes - Describe non-pharmacological and pharmacological strategies for managing patient anxiety. - Explain the difference between sedation levels and understand the limitations of training. - Have knowledge of the prescriptions for oral anxiolysis. - Justify selection of treatment. Upon completion of this section, you should be able to: - Describe non-pharmacological and pharmacological strategies for managing patient anxiety. - Explain the difference between sedation levels and understand the limitations of training. - Have knowledge of the prescriptions for oral anxiolysis. - Justify selection of treatment. # Non-pharmacological management Non-pharmacological management # Communication Strategies * Use all of the tools and tips available to create a relaxing experience. * Express empathy and reassurance. * Provide clear explanations using non-threatening languages. #### Patient Interaction and Support - Use all of the tools and tips available to create a relaxing experience. - Express empathy and reassurance. - Provide clear explanations using non-threatening languages. ## Environmental considerations * Television on the ceiling – relaxing places * Ambient sounds – music? Headphones? * Ambient scents – consider diffusion and scent profiles to distract from clinical smells * Alternate reality? VR?  #### Clinical Environment Modifications - Television on the ceiling – relaxing places - Ambient sounds – music? Headphones? - Ambient scents – consider diffusion and scent profiles to distract from clinical smells - Alternate reality? VR? Text-based conceptual diagram outlining environmental considerations. The structure lists four bullet points: 'Television on the ceiling – relaxing places', 'Ambient sounds – music? Headphones?', 'Ambient scents – consider diffusion and scent profiles to distract from clinical smells', and 'Alternate reality? VR?'. This serves as a visual summary of sensory environment strategies. Acupuncture - Origins of >2500 years in Chinese medicine - In 2003, the WHO endorsed acupuncture for pain in dentistry, including dental pain, TMJD, facial pain and postoperative pain as being a proven treatment. - Benefits shown in reducing anxiety, suppressing gag reflex and reducing pain. - In suppressing the gag reflex, CV24 and PC6 were shown to be highly effective Sari, E., & Sari, T. (2010). The role of acupuncture in the treatment of orthodontic patients with a gagging reflex: A pilot study. *British Dental Journal*, 208(10), 5. doi:https://doi.org/10.1038/sj.bdj.2010.483   #### Clinical Applications and History - Origins of >2500 years in Chinese medicine - In 2003, the WHO endorsed acupuncture for pain in dentistry, including dental pain, TMJD, facial pain and postoperative pain as being a proven treatment. - Benefits shown in reducing anxiety, suppressing gag reflex and reducing pain. - In suppressing the gag reflex, CV24 and PC6 were shown to be highly effective Sari, E., & Sari, T. (2010). The role of acupuncture in the treatment of orthodontic patients with a gagging reflex: A pilot study. *British Dental Journal*, 208(10), 5. doi:https://doi.org/10.1038/sj.bdj.2010.483 Clinical photograph (Fig. 1) showing acupuncture point CV-24 on the chin and a red-light soft magnetic field laser stimulation device applied to the area. The image demonstrates the application of acupuncture for dental or facial pain treatment. Illustration and clinical photo (Fig. 2) showing acupuncture point PC-6 on the inner wrist. Panel A is a diagram with labels, and Panel B shows a band placed over the PC-6 point. This visual supports the text's mention of PC-6 being highly effective in suppressing the gag reflex during orthodontic procedures. # Acupuncture * Origins of >2500 years in Chinese medicine * In 2003, the WHO endorsed acupuncture for pain in dentistry, including dental pain, TMJD, facial pain and postoperative pain as being a proven treatment. * Benefits shown in reducing anxiety, suppressing gag reflex and reducing pain * In suppressing the gag reflex, CV24 and PC6 were shown to be highly effective Sari, E., & Sari, T. (2010). The role of acupuncture in the treatment of orthodontic patients with a gagging reflex: A pilot study. *British Dental Journal*, 208(10), 5. doi:https://doi.org/10.1038/sj.bdj.2010.483  #### Clinical Applications and History - Origins of >2500 years in Chinese medicine - In 2003, the WHO endorsed acupuncture for pain in dentistry, including dental pain, TMJD, facial pain and postoperative pain as being a proven treatment. - Benefits shown in reducing anxiety, suppressing gag reflex and reducing pain - In suppressing the gag reflex, CV24 and PC6 were shown to be highly effective Sari, E., & Sari, T. (2010). The role of acupuncture in the treatment of orthodontic patients with a gagging reflex: A pilot study. *British Dental Journal*, 208(10), 5. doi:https://doi.org/10.1038/sj.bdj.2010.483 Clinical photo demonstrating an acupuncture procedure on a patient. The image shows a young male in profile with thin needles inserted into specific points: one needle is located at the tip of the nose (likely Shimen or nearby) and another is positioned on the ear (likely PC6). This visual serves to illustrate the physical application of acupuncture for suppressing the gag reflex, as referenced in the text. | Figure | Description | | :--- | :--- | | Fig. 1 | **A** Acupuncture point conception vessel 24 (CV 24) marked on a patient's chin. **B** A red-light soft magnetic field laser stimulation device applying stimulation to acupoint CV 24 during a dental procedure. | | Fig. 2 | **A** Schematic diagram illustrating the location of the acupuncture point PC 6 (Pericardium channel) on the inner wrist. **B** A bandage with a button attached is placed over the PC 6 point on a patient's wrist. | # Acupuncture alternatives * Can consider low level laser stimulation instead of needling. * Can use acupressure at the same point to suppress the gag reflex. <br> Sari, E., & Sari, T. (2010). The role of acupuncture in the treatment of orthodontic patients with a gagging reflex: A pilot study. *British Dental Journal*, 208(10), 5. doi:https://doi.org/10.1038/sj.bdj.2010.483   #### Point Locations and Alternative Modalities - **Fig. 1**: **A** Acupuncture point conception vessel 24 (CV 24) marked on a patient's chin. **B** A red-light soft magnetic field laser stimulation device applying stimulation to acupoint CV 24 during a dental procedure. - **Fig. 2**: **A** Schematic diagram illustrating the location of the acupuncture point PC 6 (Pericardium channel) on the inner wrist. **B** A bandage with a button attached is placed over the PC 6 point on a patient's wrist. #### Acupuncture Alternatives - Can consider low level laser stimulation instead of needling. - Can use acupressure at the same point to suppress the gag reflex. Sari, E., & Sari, T. (2010). The role of acupuncture in the treatment of orthodontic patients with a gagging reflex: A pilot study. *British Dental Journal*, 208(10), 5. doi:https://doi.org/10.1038/sj.bdj.2010.483 Clinical photograph showing acupuncture point CV-24. Panel A shows the acupoint marked on a patient's chin below the lip. Panel B shows a red-light soft magnetic field laser stimulation device being applied to the CV-24 point during a dental procedure. Illustration of acupuncture point PC-6 (Pericardium channel). Panel A is a schematic diagram showing the location of the PC-6 point on the inner wrist relative to hand anatomy. Panel B shows a physical bandage with a button placed over the PC-6 point on a patient's wrist. Hypnosis • Not necessarily the stage form that people think of. • Can be as simple as hypnotic suggestion which plays to the use of calming language to focus patient thoughts. • Hypnotic trance is similar to having a daydream. • Can be as simple as: “I want you to imagine that you are going to let yourself relax and breathe out deeply. With each breath I want you to imagine yourself to becoming more and more relaxed.” • Professional hypnotherapy may play a role in managing severe dental anxiety and has been shown to have a positive effect on smoking cessation. • However, not everyone is susceptible to hypnosis. Holden, A. (2012). The art of suggestion: The use of hypnosis in dentistry. *British Dental Journal*, 212(11), 549-51. doi:https://doi.org/10.1038/sj.bdj.2012.467 #### Hypnotic Suggestion and Trance - Not necessarily the stage form that people think of. - Can be as simple as hypnotic suggestion which plays to the use of calming language to focus patient thoughts. - Hypnotic trance is similar to having a daydream. - Can be as simple as: “I want you to imagine that you are going to let yourself relax and breathe out deeply. With each breath I want you to imagine yourself to becoming more and more relaxed.” - Professional hypnotherapy may play a role in managing severe dental anxiety and has been shown to have a positive effect on smoking cessation. - However, not everyone is susceptible to hypnosis. Holden, A. (2012). The art of suggestion: The use of hypnosis in dentistry. *British Dental Journal*, 212(11), 549-51. doi:https://doi.org/10.1038/sj.bdj.2012.467 Hypnosis • Hypnosis has been used to induce anaesthesia, first recorded in 1829 for dental extraction. • The deeper forms require significant more time and training for operators to do safely. • More recent teams have shown the ability to remove wisdom teeth under hypnotic suggestion only¹ 1. Abdeshahi, Seyyed Kazem et al, ‘Effect of Hypnosis on Induction of Local Anaesthesia, Pain Perception, Control of Haemorrhage and Anxiety during Extraction of Third Molars: A Case–Control Study’ (2013) 41(4) Journal of cranio-maxillo-facial surgery 310  #### Clinical Hypnosis and Anaesthesia - Hypnosis has been used to induce anaesthesia, first recorded in 1829 for dental extraction. - The deeper forms require significant more time and training for operators to do safely. - More recent teams have shown the ability to remove wisdom teeth under hypnotic suggestion only. Abdeshahi, Seyyed Kazem et al, ‘Effect of Hypnosis on Induction of Local Anaesthesia, Pain Perception, Control of Haemorrhage and Anxiety during Extraction of Third Molars: A Case–Control Study’ (2013) 41(4) Journal of cranio-maxillo-facial surgery 310 Reference citation figure: Text-based citation for a case-control study by Abdeshahi et al. (2013) on the effect of hypnosis during third molar extraction, including journal name and page number. # Cognitive Behaviour Therapy [CBT] * CBT is the intersect of cognitive therapy and behavioural therapy. * CBT does not aim to define the root cause of the problem but to solve the problem by identifying beliefs that lead to current thoughts and behaviours. * Evidence suggests that it can not only help to reduce self-reported dental anxiety but it can also help to improve long term attendance[^1^](#ref1). * Requires referral to specialized psychology services. * Requires the patient to actively want to manage their condition. * Would be considered a complementary therapy to other forms of sedation. --- [^1^]: Kvale, Gerd, Ulf Berggren and Peter Milgrom, ‘Dental Fear in Adults: A Meta-Analysis of Behavioral Interventions’ (2004) 32(4) Community dentistry and oral epidemiology 250 #### Principles and Application of CBT - CBT is the intersect of cognitive therapy and behavioural therapy. - CBT does not aim to define the root cause of the problem but to solve the problem by identifying beliefs that lead to current thoughts and behaviours. - Evidence suggests that it can not only help to reduce self-reported dental anxiety but it can also help to improve long term attendance. - Requires referral to specialized psychology services. - Requires the patient to actively want to manage their condition. - Would be considered a complementary therapy to other forms of sedation. Kvale, Gerd, Ulf Berggren and Peter Milgrom, ‘Dental Fear in Adults: A Meta-Analysis of Behavioral Interventions’ (2004) 32(4) Community dentistry and oral epidemiology 250 <img>Pharmacological management with image of Midazolam Injection vial NDC 0641-6060-01 R only RxE only  Pharmacological management involves the administration of sedative agents, such as Midazolam, to alleviate patient anxiety during surgical procedures. Clinical photo of a Midazolam Injection vial. The label indicates 'Midazolam Injection, USP', concentration '50 mg/10 mL (5 mg/mL)', and volume '10 mL Vial'. It specifies usage as 'FOR IM OR IV USE ONLY' and notes it 'CONTAINS BENZYL ALCOHOL'. The NDC number is 0641-6060-01. # Definitions • **Minimal sedation** (also known as anxiolysis) is a drug-induced state of diminished anxiety, during which patients are conscious and respond purposefully to verbal commands or light tactile stimulation. The drugs used are oral benzodiazepines or inhaled agents (nitrous oxide or, less commonly, methoxyflurane). Cognitive function and coordination may be impaired during minimal sedation, but no interventions are required to maintain a patent airway, spontaneous ventilation or cardiovascular function. • **Moderate sedation** is a drug-induced state of depressed consciousness, during which patients retain the ability to respond purposefully to verbal commands and tactile stimulation. It involves the use of intravenous drugs or a combination of oral drugs and inhalational techniques. In exceptional circumstances, interventions to maintain a patent airway, spontaneous ventilation or cardiovascular function may be required. • **Deep sedation** is a drug-induced state of depressed consciousness, during which patients are not easily roused and may respond only to noxious stimulation. Features of deep sedation include impaired ability to maintain an airway, inadequate spontaneous ventilation and impaired cardiovascular function. \*TGA Guidelines #### TGA Sedation Guidelines - **Minimal sedation (Anxiolysis)** - A drug-induced state of diminished anxiety where patients remain conscious. - Patients respond purposefully to verbal commands or light tactile stimulation. - Typically achieved using oral benzodiazepines or inhaled agents (nitrous oxide or, less commonly, methoxyflurane). - While cognitive function and coordination may be impaired, no interventions are required to maintain a patent airway, spontaneous ventilation, or cardiovascular function. - **Moderate sedation** - A drug-induced state of depressed consciousness. - Patients retain the ability to respond purposefully to verbal commands and tactile stimulation. - Involves intravenous drugs or a combination of oral drugs and inhalational techniques. - Interventions to maintain a patent airway, spontaneous ventilation, or cardiovascular function may be required in exceptional circumstances. - **Deep sedation** - A drug-induced state of depressed consciousness where patients are not easily roused. - Patients may respond only to noxious stimulation. - Characterized by an impaired ability to maintain an airway, inadequate spontaneous ventilation, and potentially impaired cardiovascular function. · Dentists are restricted to providing minimal sedation (with appropriate training). · Dentists can provided moderate sedation if they are endorsed by the Dental Board, after completion of an approved course of study. · Currently limited to the University of Sydney Graduate Diploma in Clinical Dentistry (Conscious Sedation and Pain Control) · Deep sedation is restricted to trained medical practitioners and anaesthetists in approved facilities. #### Practitioner Restrictions and Endorsements - **Minimal Sedation** - Dentists are restricted to providing minimal sedation, provided they have received appropriate training. - **Moderate Sedation** - Dentists can provide moderate sedation only if they are endorsed by the Dental Board. - Endorsement requires the completion of an approved course of study, currently limited to the University of Sydney Graduate Diploma in Clinical Dentistry (Conscious Sedation and Pain Control). - **Deep Sedation** - Restricted to trained medical practitioners and anaesthetists. - Must be performed within approved facilities. - Guedel (1937) described 4 stages of anaesthesia: - Stage 1 – Stage of analgesia (induction through to loss of consciousness) - Stage 2 – Stage of excitement (loss of consciousness to onset of automatic breathing) - Stage 3 – State of surgical anaesthesia (automatic breathing to respiratory paralysis) - This is the stage where general anaesthetic surgery takes place and patients are maintained - Stage 4 – Respiratory paralysis - death Guedel (1937) described four distinct stages of anaesthesia: 1. **Stage 1: Stage of analgesia** - From induction through to the loss of consciousness. 2. **Stage 2: Stage of excitement** - From the loss of consciousness to the onset of automatic breathing. 3. **Stage 3: State of surgical anaesthesia** - From the onset of automatic breathing to respiratory paralysis. - This is the stage where general anaesthetic surgery takes place and patients are maintained. 4. **Stage 4: Respiratory paralysis** - Leads to death if not managed. # Relative Analgesia – RA * Commonly known as inhalation sedation – ADA Code 943 (per 30mins or part there of) * Should be considered the first line option for children requiring sedation. * Using nitrous oxide (N₂O) * Colourless, sweet smelling gas * 1.5 times heavier than air * Non-irritating * Stored as a liquid in a blue cylinder * Non-flammable BUT will support the combustion of other agents * Good analgesic agent – 50% N₂O is similar to 10-15mg of morphine Relative Analgesia (RA) is commonly known as inhalation sedation (ADA Code 943, per 30 mins or part thereof). It should be considered the first-line option for children requiring sedation. #### Properties of Nitrous Oxide (N₂O) - Colourless, sweet-smelling gas - 1.5 times heavier than air - Non-irritating - Stored as a liquid in a blue cylinder - Non-flammable, but will support the combustion of other agents - Effective analgesic agent: 50% N₂O is similar to 10–15mg of morphine # Nitrous Oxide * An N-Methyl-D-aspartate (NMDA) receptor antagonist which produces a dissociative anaesthetic effect. * Releases endogenous opioids acting on opioid receptors to produce analgesic effect. * GABA-A activation produces anxiolytic effect. * Due to rapid elimination at the end of the procedure, N$_2$O entering the alveoli can displace O$_2$ causing a diffusion hypoxia. * This is overcome by giving 100% O$_2$ for 2-5 minutes at the end of the procedure * Acts in stage 1 of Gudel's stages (state of analgesia) #### Pharmacodynamics - **NMDA Receptor Antagonist:** Produces a dissociative anaesthetic effect. - **Opioid Interaction:** Releases endogenous opioids acting on opioid receptors to produce an analgesic effect. - **GABA-A Activation:** Produces an anxiolytic effect. - **Guedel's Stages:** Acts in Stage 1 (state of analgesia). #### Diffusion Hypoxia Due to rapid elimination at the end of the procedure, N₂O entering the alveoli can displace O₂ causing diffusion hypoxia. This is overcome by administering 100% O₂ for 2–5 minutes at the end of the procedure. # Indications for RA * Fear and anxiety * Pain control * Medical conditions made worse by stress * Gagging * Traumatic or complex dental procedures\* # Contraindications to RA ## * Psychosocial * * Claustrophobic patients * * Lack of understanding of process – either age or learning difficulties * * Severe anxiety * * Complexity of dental treatment ## * Medical * * Nasal obstructions – upper respiratory tract infections * * ASA III (IV or V) – severe systemic disease * * COPD * * Pregnancy (1st trimester) * * *Severe psychiatric disorders ## * Dental * * Upper anterior procedures\* #### Indications - Fear and anxiety - Pain control - Medical conditions exacerbated by stress - Gagging - Traumatic or complex dental procedures #### Contraindications **Psychosocial** - Claustrophobic patients - Lack of understanding of the process (due to age or learning difficulties) - Severe anxiety - Complexity of dental treatment **Medical** - Nasal obstructions (e.g., upper respiratory tract infections) - ASA III, IV, or V (severe systemic disease) - COPD - Pregnancy (1st trimester) - Severe psychiatric disorders **Dental** - Upper anterior procedures **Advantages of RA** * Safe * Rapid onset and recovery (low blood solubility of 0.47) * Easily regulated * Drug not metabolized * No adverse effects on CVS, RS. Liver or kindeys * Analgesic * Limited amnesia **Disadvantages of RA** * Special equipment required * Large variation in response * Care if chronically exposed (staff) * Potential for abuse * Limited amnesia #### Advantages - Safe - Rapid onset and recovery (low blood solubility of 0.47) - Easily regulated - Drug is not metabolized - No adverse effects on CVS, RS, liver, or kidneys - Analgesic properties - Limited amnesia #### Disadvantages - Special equipment required - Large variation in patient response - Risks associated with chronic exposure for staff - Potential for abuse - Limited amnesia # Risks of chronic exposure - More likely associated with healthcare workers in operating theatres but long-term exposure can cause: - Deactivation of vitamin B12 causing neurological symptoms (peripheral neuropathy) - Toxic hepatic effects (inhibition of liver enzymes) - Depression of leukocyte production - Spontaneous abortion and reproductive issues Eftimova B, Sholjakova M, Mirakovski D, Hadzi-Nikolova M. Health Effects Associated With Exposure to Anesthetic Gas Nitrous Oxide-N2O in Clinical Hospital - Shtip Personnel. Open Access Maced J Med Sci. 2017 Oct 10;5(6):800-804. doi: 10.3889/oamjms.2017.185 While more commonly associated with healthcare workers in operating theatres, long-term exposure to nitrous oxide can cause: - **Neurological Symptoms:** Deactivation of vitamin B12 leading to peripheral neuropathy. - **Hepatic Effects:** Toxic inhibition of liver enzymes. - **Hematological Effects:** Depression of leukocyte production. - **Reproductive Issues:** Spontaneous abortion and other reproductive complications. The general setup - Gas: - Bottled gas on a trolley - Piped gas - Control unit (similar for both delivery methods) - Different to Entenox unit in delivery suites.  #### Gas Delivery Systems - **Bottled Gas:** Supplied on a mobile trolley. - **Piped Gas:** Integrated into the facility infrastructure. #### Control Unit The control unit is similar for both delivery methods but differs from the Entonox units typically found in delivery suites. Labeled photograph of a Quantiflex MDM gas flowmeter setup. The device features two vertical glass flowmeters flanking a central control panel with dials and a black base. Labels point to specific components: 'N₂O flow rate' (left meter), '% N₂O control' (left dial), 'O₂ flow rate' (right meter), 'Flow rate adjustment' (central dial), and 'O₂ Flush' (bottom nozzle). # The general setup ### Reservoir bag #### Nasal hood + scavenging • Reservoir bag attached • Nasal hood to patient • Scavenging is an important part of the setup • In general, active scavenging is used by connecting suction hose to the hood • Requires a good fit – different sizes available  #### Reservoir Bag and Nasal Hood - **Reservoir Bag:** Attached to the system to manage gas volume. - **Nasal Hood:** Delivers the gas mixture to the patient; available in different sizes to ensure a good fit. - **Scavenging:** A critical safety component. Active scavenging is generally used by connecting a suction hose to the hood. Clinical photo showing a patient in a dental chair receiving treatment. The image demonstrates the general setup described in the OCR text: a reservoir bag is attached to the anesthesia machine (visible on the left), and a nasal hood with scavenging tubing is applied to the patient's nose. A healthcare professional wearing blue gloves is adjusting the equipment. # The general setup • Different types of hood exist, but this type is the most effective • Inner hood delivers mixture • One way valve allows gases into the outer hood where the scavenging system is connected  #### Hood Design Various types of hoods exist, but the double-hood design is the most effective: - **Inner Hood:** Delivers the gas mixture. - **Outer Hood:** Connected to the scavenging system. - **One-way Valve:** Allows gases to pass into the outer hood for removal. Clinical photo showing three different types of anesthesia hoods. The image includes a clear plastic hood with an attached corrugated tube in the foreground, and two beige-colored soft hoods in the background. The visual supports the OCR text describing the 'general setup' where an inner hood delivers gas mixture to a patient, while a one-way valve directs gases into the outer hood for scavenging. # The general setup ^more common double hood ^newer style Silhouette mask   Common equipment variations include the standard double hood and the newer style Silhouette mask. Photo of a medical device setup labeled 'more common double hood', showing two beige nasal mask hoods and one clear plastic breathing circuit with an elbow connector. Photo of a patient wearing a newer style Silhouette mask, which is a thin, transparent nasal cannula-style interface fitting over the nose with tubing extending to the side. # Important safety features - Pin index system on gas bottles - Colour coding - Oxygen flush - Oxygen fail safe - Reservoir bag - Minimum O₂ delivery of 30% - One-way valves #### Safety Mechanisms - **Pin Index System:** Prevents incorrect connection of gas bottles. - **Colour Coding:** For easy identification of gases. - **Oxygen Flush:** Provides immediate 100% oxygen. - **Oxygen Fail-Safe:** Automatically shuts off nitrous oxide if oxygen pressure drops. - **Reservoir Bag:** Visual indicator of breathing and gas volume. - **Minimum Oxygen Delivery:** Ensures a minimum of 30% O₂ is always delivered. - **One-way Valves:** Prevents rebreathing of exhaled gases. A brief overview of the steps • Consent should be done at a prior visit. • Chaperone in the room. • Patient places the hood and a low flow rate of 4-6L/min O$_2$ is started. Hood is adjusted for comfortable and sealed fit. Checking limited leakage over eyes. • Ensure nasal inspiration and expiration only - may need practice. • Good practice for pulse oximetry monitoring. • Start to increase % nitrous, 5-10% in increments 1-2mins until desired level reached (usually 35-45%). • Effects of nitrous oxide are rapid with peak brain levels in 5-7mins. • Hypnotic suggestion can help to improve the sedative effect. #### Preparation and Induction 1. **Consent:** Should be obtained at a prior visit. 2. **Chaperone:** Must be present in the room. 3. **Positioning:** The patient places the hood. Start a low flow rate of 4–6 L/min O₂. Adjust the hood for a comfortable, sealed fit, ensuring limited leakage over the eyes. 4. **Breathing Technique:** Ensure nasal inspiration and expiration only; the patient may require practice. 5. **Monitoring:** Pulse oximetry is considered good practice. 6. **Titration:** Increase nitrous oxide in increments of 5–10% every 1–2 minutes until the desired level is reached (typically 35–45%). #### Onset and Enhancement - Peak brain levels are reached within 5–7 minutes. - Hypnotic suggestion can be used to improve the sedative effect. # Signs of adequate levels * Relaxed and appearing comfortable * Tingling in hands and feet * Reduction in movements * May be lightly giggly or feelings of euphoria * Reduced awareness of physical stimuli * Patient indicating happy to proceed with treatment #### Clinical Indicators - Patient appears relaxed and comfortable. - Tingling sensations in hands and feet. - Reduction in physical movements. - Light giggling or feelings of euphoria. - Reduced awareness of physical stimuli. - Patient indicates they are happy to proceed with treatment. ## Monitoring during procedure * Ensure remain responsive. * Colour and pulse oximetry from time to time. * Main difficulty is monitoring and assessing flow rate so as not to under or over deliver. #### Ongoing Assessment - Ensure the patient remains responsive throughout the procedure. - Monitor patient colour and pulse oximetry periodically. - Assess and adjust flow rates carefully to avoid under- or over-delivery. # Recovery stage - Once treatment complete, or nearing completion, 100% O₂ delivered for 5 minutes. - Preventing diffusion hypoxia. - Remove the nasal hood, sit the patient up and make sure they don’t feel dizzy. - Children must be accompanied by an adult and supervised for the rest of the day. #### Post-Operative Protocol - **Oxygenation:** Once treatment is nearing completion or finished, deliver 100% O₂ for 5 minutes to prevent diffusion hypoxia. - **Assessment:** Remove the nasal hood, sit the patient up, and ensure they do not feel dizzy. - **Supervision:** Children must be accompanied by an adult and supervised for the remainder of the day. If N2O is used in your practice, you will need practical training to support its use. Once per year the ADA WA run a course that would be sufficient for you to introduce it into practice. **6.5 CPD hours** Discount 5 SEP **Anxiolysis and Relative Analgesia (N2O) in Modern Dental Practice** ✈ PERTH From $1,095.00 incl. GST  #### Professional Requirements Practical training is required to support the use of N₂O in practice. The ADA WA conducts a qualifying course once per year. **Course Details:** - **Title:** Anxiolysis and Relative Analgesia (N₂O) in Modern Dental Practice - **Location:** Perth - **Credit:** 6.5 CPD hours - **Cost:** From $1,095.00 incl. GST Screenshot of a course advertisement poster for 'Anxiolysis and Relative Analgesia (N2O) in Modern Dental Practice' held on September 5th in Perth. The image includes visual details such as N2O equipment visible at the top left, alongside text indicating 6.5 CPD hours, a discount offer, and pricing information. # Methoxyflurane (Penthrox) An inhaled analgesic indicated for the emergency relief of pain associated with trauma, and for analgesia in monitored conscious patients during surgical procedures. - Used off-label in a dental setting and has a limited role. - It may have a role in pain mitigation in short procedures, such as treating alveolar osteitis. - Absorbed into fatty tissues, so slower reversal of effects. - Ensure patients exhale through the activated carbon filter in the device. - Maximum recommended use is 6mL/week or 15mL/week.  Methoxyflurane is an inhaled analgesic indicated for the emergency relief of pain associated with trauma, and for analgesia in monitored conscious patients during surgical procedures. #### Clinical Application and Limitations - Used off-label in a dental setting and has a limited role. - It may have a role in pain mitigation in short procedures, such as treating alveolar osteitis. #### Administration and Safety - Absorbed into fatty tissues, resulting in a slower reversal of effects. - Ensure patients exhale through the activated carbon filter in the device. - Maximum recommended use is 6mL per day or 15mL per week. Clinical product photograph of a Methoxyflurane inhaler device (brand name Penthrox). The image shows the white and green plastic canister with the 'Penthrox' logo printed on it, connected to a clear mouthpiece assembly containing an activated carbon filter. This visual corresponds to the OCR context describing Methoxyflurane as an inhaled analgesic used for pain relief during dental procedures. # Oral Benzodiazepines **Advantages** * Well-accepted by patients * Cost effective * Easy to administer * Provides anxiolysis prior to the procedure **Disadvantages** * Slow onset and long duration of action * Supervision required post procedure * Variable response * Cannot be titrated rapidly * Used in caution with certain patients * Older / frail / cognitively impaired / OSA * Cannot be used if patient does not have an escort/carer to look after them #### Advantages - Well-accepted by patients - Cost effective - Easy to administer - Provides anxiolysis prior to the procedure #### Disadvantages - Slow onset and long duration of action - Supervision required post procedure - Variable response - Cannot be titrated rapidly - Used in caution with certain patients - Older / frail / cognitively impaired / OSA - Cannot be used if patient does not have an escort/carer to look after them Oral Benzodiazepines <br> **Indications** * Dental anxiety * Short procedure 1-2hrs maximum <br> **Contraindications** * Prolonged procedures * Severely limiting heart, cerebrovascular, lung, liver or kidney disease. * Allergies or other adverse events in relation to drugs used in sedation, analgesia or anaesthesia. * Severe anxiety that has not been managed effectively with minimal sedation. * Substance abuse. #### Indications - Dental anxiety - Short procedure (1-2 hours maximum) #### Contraindications - Prolonged procedures - Severely limiting heart, cerebrovascular, lung, liver, or kidney disease - Allergies or other adverse events in relation to drugs used in sedation, analgesia, or anaesthesia - Severe anxiety that has not been managed effectively with minimal sedation - Substance abuse <Table> <tr> <th>Name of drug</th> <th>Dose (for >13yrs)</th> <th>Notes</th> </tr> <tr> <td>Temazepam 10mg tablet</td> <td>10mg, orally, 1 hour prior to the procedure. To be taken at the dental practice.</td> <td>If ineffective, to consider increasing the dose to 20mg (caution in >75yrs or frail)</td> </tr> <tr> <td>Lorazepam 1mg tablet</td> <td>1mg, orally, 1 hour prior to the procedure. To be taken at the dental practice.</td> <td>If ineffective, to consider increasing the dose to 2mg (caution in >75yrs or frail)</td> </tr> <tr> <td>Diazepam 2mg tablet</td> <td>2-5mg, orally, 1 hour prior to the procedure. To be taken at the dental practice.</td> <td>Use the lower end of the dose range for >75yrs or frail</td> </tr> </Table>  #### Recommended Dosages (Patients >13 Years) 1. **Temazepam (10mg tablet)** - **Dose:** 10mg orally, 1 hour prior to the procedure. To be taken at the dental practice. - **Notes:** If ineffective, consider increasing the dose to 20mg (use caution in patients >75 years or frail). 2. **Lorazepam (1mg tablet)** - **Dose:** 1mg orally, 1 hour prior to the procedure. To be taken at the dental practice. - **Notes:** If ineffective, consider increasing the dose to 2mg (use caution in patients >75 years or frail). 3. **Diazepam (2mg tablet)** - **Dose:** 2-5mg orally, 1 hour prior to the procedure. To be taken at the dental practice. - **Notes:** Use the lower end of the dose range for patients >75 years or frail. A structured table titled 'Oral Benzodiazepines' with three columns: 'Name of drug', 'Dose (for >13yrs)', and 'Notes'. It lists three drugs—Temazepam 10mg tablet, Lorazepam 1mg tablet, and Diazepam 2mg tablet—with their respective dosing instructions for adults over 13 years old and specific notes on dose adjustments or cautions for elderly or frail patients. # Oral Benzodiazepines **Technique** * Written consent prior to the day of the procedure. * Thorough medical history – ensure not already taking. * Clear instructions for the day of the procedure, including someone to drive home. * Prescription to dispense the medication for the procedure only. * If multiple visits are required then give prescription at each visit. * This will ensure patients are only supplied with one dose and can adjust dose if necessary. * Schedule the patient to arrive at the practice one hour beforehand to take the medication. #### Clinical Technique - Obtain written consent prior to the day of the procedure. - Conduct a thorough medical history to ensure the patient is not already taking these medications. - Provide clear instructions for the day of the procedure, including the requirement for someone to drive the patient home. - Issue a prescription to dispense the medication for the procedure only. - If multiple visits are required, provide a prescription at each visit. - This ensures patients are only supplied with one dose and allows for dose adjustments if necessary. - Schedule the patient to arrive at the practice one hour beforehand to take the medication. # Oral Benzodiazepines at E Block * If required, Temazepam 10mg is the benzodiazepine dispensed. * It is dispensed on site, 1 hour prior to the procedure. #### E Block Local Protocol - If required, Temazepam 10mg is the benzodiazepine dispensed. - It is dispensed on site, 1 hour prior to the procedure. # IV Sedation - Can only be provided by a suitably trained individual as this is now moderate sedation. - Dentist – limited to single drug sedation. - Medical practioner – Anaesthetist or GP Anaesthetist. - Must have at least 3 staff members present in the room – proceduralist, seditionist and assistant. - Facilities must allow for rapid access of emergency services if required. - Enhanced dental team training should be undertaken – advanced life support with oxygen therapy (HLTAID015 or similar). - AED and airway adjuncts must be available. - Sufficient patient monitoring should be performed: - HR, BP, O2 saturation, ideally expired capnography[^1] ANZCA PG09 – Guideline on procedural sedation 2023 [^1]: Reference superscript in original text. Intravenous sedation is classified as moderate sedation and must be managed according to strict safety and staffing guidelines. #### Personnel Requirements - Must be provided by a suitably trained individual: - Dentist: Limited to single drug sedation. - Medical practitioner: Anaesthetist or GP Anaesthetist. - A minimum of three staff members must be present in the room: the proceduralist, the sedationist, and an assistant. #### Facility and Training Standards - Facilities must allow for rapid access by emergency services if required. - The dental team should undertake enhanced training, such as advanced life support with oxygen therapy (HLTAID015 or similar). - Essential equipment must be available, including an Automated External Defibrillator (AED) and airway adjuncts. #### Patient Monitoring Sufficient monitoring must be performed throughout the procedure, including: - Heart Rate (HR) - Blood Pressure (BP) - Oxygen (O2) saturation - Ideally, expired capnography *Reference: ANZCA PG09 – Guideline on procedural sedation 2023* # IV Sedation * Midazolam * Drug used for dentist sedationist (single pharmacy), used in combination with other drugs when given by anaesthetist. * Benzodiazepine acting on GABA$_a$ receptors and enhancing the affinity for GABA * No pain on injection * Metabolised in the liver * Short half life (2hrs) * Clinical working time of approximately 45mins * Some amnesia, but effect decreases with time * Reversible with Flumazenil * Caution with rebound sedation (half life of 50minutes) #### Midazolam - **Usage:** The primary drug used for single-drug sedation by dentists; also used in combination with other agents when administered by an anaesthetist. - **Mechanism:** A benzodiazepine that acts on GABA_a receptors, enhancing the affinity for GABA. - **Administration:** No pain on injection. - **Metabolism:** Processed in the liver with a short half-life of approximately 2 hours. - **Clinical Profile:** - Working time of approximately 45 minutes. - Provides some amnesia, though the effect decreases over time. - **Reversal:** Can be reversed with Flumazenil. - *Caution:* Risk of rebound sedation due to Flumazenil's 50-minute half-life. # IV Sedation * **Propofol** * Anaesthetic induction agent * Short half life (2-5minutes) so given as a continuous infusion (on a pump) * Provides the sedation * **Remifentanil** * Short acting synthetic opioid * Used synergistically with propofol * Provides a level of analgesia * **Other drugs** * May also want to give antibiotics, steroids or other analgesics IV #### Propofol - **Type:** Anaesthetic induction agent. - **Administration:** Given as a continuous infusion via a pump due to a very short half-life (2–5 minutes). - **Function:** Provides the primary sedation. #### Remifentanil - **Type:** Short-acting synthetic opioid. - **Function:** Used synergistically with propofol to provide a level of analgesia. #### Adjunctive Medications - Other intravenous drugs may be administered as needed, including: - Antibiotics - Steroids - Additional analgesics # IV Sedation **Advantages** * Operator can focus on dentistry. * Well tolerated. * Suppresses gag reflex. * Suppresses anxiety. **Disadvantages** * Cost * If dentist – 942 code (sedation – IV – per 30min) * If anaesthetist – operator charges 949 and anaesthetist bills separately ($$) #### Advantages - Allows the operator to focus entirely on the dental procedure. - Generally well tolerated by patients. - Effectively suppresses the gag reflex. - Effectively suppresses patient anxiety. #### Disadvantages and Costs - **Financial Cost:** - If performed by a dentist: Billed under code 942 (sedation – IV – per 30 min). - If performed by an anaesthetist: The dental operator charges code 949, and the anaesthetist bills separately. **MEDICARE - STANDARD REBATES** After the sedation has finished and payment is finalised, we will give you a receipt to claim any Medicare rebate. The table below shows an extract from our current fee schedule with expecte **standard** Medicare rebates as at 1 July 2024. Note that as an out-of-hospital service, it is not usually covered by Private Health Insurance. | TIME | 45 mins | 1 hour | 1 hr 30 m | 2 hours | 2 hr 30 m | 3 hours | |---|---|---|---|---|---|---| | FEE | $1,090 | $1,220 | $1,480 | $1,740 | $2,010 | $2,280 | | REBATE | $214.90 | $234.05 | $272.40 | $310.70 | $368.20 | $425.70 | | TIME | 3 hr 30 m | 4 hours | 4hr 30 m | 5 hours | 5 hr 30 m | 6 hours | |---|---|---|---|---|---|---| | FEE | $2,550 | $2,820 | $3,090 | $3,360 | $3,630 | $3,900 | | REBATE | $483.20 | $540.70 | $598.25 | $655.75 | $713.25 | $780.25 | **MEDICARE - EXTENDED MEDICARE SAFETY NET** Medicare may also provide an **additional rebate** once an annual (calendar year) threshold of ouf-out-of-pocket costs for out-of-hospital medical services has been reached by you or your safety net family. Medicare will then reimburse up to **80%** of out-of-pocket costs for out-of-hospital medical services for you and your family for the rest of the calendar year. Check with Medicare 1 confirm your safety net rebate eligibility and the current expected rebate for this sedation.  #### Standard Medicare Rebates Upon completion of sedation and finalisation of payment, a receipt is provided to claim Medicare rebates. As an out-of-hospital service, this is typically not covered by Private Health Insurance. The following table outlines the fee schedule and expected standard rebates as of 1 July 2024: | Duration | Fee | Standard Rebate | | :--- | :--- | :--- | | 45 mins | $1,090 | $214.90 | | 1 hour | $1,220 | $234.05 | | 1 hr 30 m | $1,480 | $272.40 | | 2 hours | $1,740 | $310.70 | | 2 hr 30 m | $2,010 | $368.20 | | 3 hours | $2,280 | $425.70 | | 3 hr 30 m | $2,550 | $483.20 | | 4 hours | $2,820 | $540.70 | | 4 hr 30 m | $3,090 | $598.25 | | 5 hours | $3,360 | $655.75 | | 5 hr 30 m | $3,630 | $713.25 | | 6 hours | $3,900 | $780.25 | #### Extended Medicare Safety Net Medicare may provide an additional rebate once an annual calendar year threshold for out-of-pocket costs for out-of-hospital medical services is reached. - Medicare may reimburse up to 80% of out-of-pocket costs for the remainder of the calendar year. - Patients should verify safety net eligibility and current rebate rates directly with Medicare. A table detailing 'MEDICARE - STANDARD REBATES' as of 1 July 2024. It lists sedation durations from 45 minutes to 6 hours, corresponding FEE amounts, and REBATE values. The table is split into two blocks: the first covers 45 mins to 3 hours, and the second covers 3 hr 30 m to 6 hours. # IV Sedation ## Advantages * Operator can focus on dentistry. * Well tolerated. * Suppresses gag reflex. * Suppresses anxiety. ## Disadvantages * Cost * If dentist – 942 code (sedation – IV – per 30min) * If anaesthetist – operator charges 949 and anaesthetist bills separately ($$) * Trained staff required * Requirements for facilities * Procedural time significantly increased #### Clinical Advantages - Operator can focus on dentistry. - Well tolerated. - Suppresses gag reflex. - Suppresses anxiety. #### Clinical Disadvantages - **Cost:** - Dentist-led: Code 942 (IV sedation per 30 min). - Anaesthetist-led: Operator charges 949; anaesthetist bills separately. - Requires specifically trained staff. - Specific facility requirements must be met. - Procedural time is significantly increased. # IV Sedation Technique * Consent forms signed ahead of procedure * Patient is fasted prior to attending * Person providing the sedation gains IV access and establishes the operating conditions (5-20mins) * Required treatment takes place (generally taking 20-40% longer than without sedation) * Recovery – variable time 10-30mins to leave the surgery * Will recover for a further 20-30mins in a safe and supervised environment * Discharged home with a responsible person who will look after them * No driving, operating heavy machinery or signing legal documents for 24hrs #### Procedural Workflow 1. **Preparation:** Consent forms must be signed ahead of the procedure, and the patient must be fasted prior to attendance. 2. **Induction:** The sedation provider gains IV access and establishes operating conditions (5–20 minutes). 3. **Treatment:** The dental procedure is performed; this generally takes 20–40% longer than it would without sedation. 4. **Initial Recovery:** Variable time of 10–30 minutes before the patient can leave the immediate surgery area. 5. **Supervised Recovery:** The patient recovers for a further 20–30 minutes in a safe, supervised environment. #### Discharge Requirements - Patients are discharged home only with a responsible person to look after them. - For 24 hours post-procedure, patients must not: - Drive - Operate heavy machinery - Sign legal documents IV Sedation at E Block • There is no current IV Sedation service available at E block #### Local Availability - There is no current IV Sedation service available at E block. # General Anaesthetic * "The primary goal of general anaesthesia is to render a patient unconscious and unable to feel painful stimuli while controlling autonomic reflexes” 1 1 * Will take place in specialized facilities * Private or public * May be day case or require overnight stay * Decision for GA may be based on several factors: * Procedural difficulty and ability to anaesthetise with LA * Procedural length * Procedure unpleasantness * Patient preference 1. Smith G, D'Cruz JR, Rondeau B, et al. General Anesthesia for Surgeons. [Updated 2023 Aug 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493199/ The primary goal of general anaesthesia is to render a patient unconscious and unable to feel painful stimuli while controlling autonomic reflexes. #### Clinical Setting and Facilities General anaesthesia takes place in specialized facilities, which may be private or public. These procedures may be performed as day cases or may require an overnight stay. #### Indications for General Anaesthesia The decision to utilize general anaesthesia may be based on several factors: - Procedural difficulty and the ability to effectively anaesthetise with local anaesthetic (LA) - Procedural length - Unpleasantness of the procedure - Patient preference # General Anaesthetic * In Perth – general dentists can only be accredited to a small number of private day hospital facilities * If performing restorative treatment, it all must be brought from the clinic * OMF surgeons are accredited across both private and public hospitals * Special needs dentists may operate within their departmental configurations at RPH and FSH * Paediatric dentists may operate across public and private facilities depending on job role #### Practitioner Accreditation in Perth - **General Dentists:** Can only be accredited to a small number of private day hospital facilities. If performing restorative treatment, all necessary equipment must be brought from the clinic. - **Oral and Maxillofacial (OMF) Surgeons:** Accredited across both private and public hospitals. - **Special Needs Dentists:** May operate within their departmental configurations at Royal Perth Hospital (RPH) and Fiona Stanley Hospital (FSH). - **Paediatric Dentists:** May operate across public and private facilities depending on their specific job role. # General Anaesthetics at E Block - OHCWA use Southbank Day Surgery as their operating facility - Southbank Day Surgery has specific criteria that must be met for acceptance - Weight <130kg - BMI <40 (exceptions can be made up to 42) - No OSA  #### OHCWA Operating Facility Oral Health Centre of WA (OHCWA) uses Southbank Day Surgery as their operating facility. Southbank Day Surgery has specific criteria that must be met for patient acceptance: - Weight < 130kg - BMI < 40 (exceptions can be made up to 42) - No Obstructive Sleep Apnoea (OSA) Text-based procedural outline detailing the criteria for General Anaesthetics at E Block. It specifies that OHCWA use Southbank Day Surgery as their operating facility and lists acceptance criteria: Weight <130kg, BMI <40 (with exceptions up to 42), and No OSA. <table> <tr> <th>Weight in KG</th> <th></th> <th><b>BMI Must be calculated</b></th> <th>Accepted for surgery</th> <th>Conditions</th> </tr> <tr> <td>Weight greater than 130 kg</td> <td></td> <td>N/A</td> <td>Not Accepted</td> <td>Not Negotiable</td> </tr> <tr> <td colspan="5"></td> </tr> <tr> <td>Any weight (even under 100kg)</td> <td>AND</td> <td>BMI 40 - 42</td> <td>Must meet criteria below to be accepted and in consultation with GM/DON and Operations Director WA or National Clinical Governance Director</td> </tr> <tr> <td>Any weight (even under 100kg)</td> <td>AND</td> <td>BMI 38 - 40</td> <td>Must meet criteria below to be accepted and in consultation with GM/DON</td> </tr> <tr> <td>Weight less than 130kg</td> <td>AND</td> <td>BMI Equal or less than 35</td> <td>Accepted</td> <td>If Clinically accepted by Anaesthetist</td> </tr> <tr> <td>Any Weight Less than 130kg</td> <td>AND</td> <td>BMI 35-38</td> <td>Must meet criteria to be accepted</td> <td><b>Criteria:</b> <ul><li>ASA 1 or 2 (BMI should not be included as part of ASA criteria)</li><li>No Sleep apnoea</li><li>No respiratory disease of any significance.</li><li>No anticipated airway difficulty.</li><li>Patient is normally ambulant with minimal assistance.</li><li>Patients should be booked as morning cases or first on afternoon list.</li><li>All patients must be reviewed by Anaesthetist prior to surgery and approved by DON/Clinical Nurse</li><li>Early consultation (Anaesthetist's rooms) prior admission is preferable.</li></ul></td> </tr> </table> **Manual Handling** * All patients over 90kg (if capable and not sedated) should self-ambulate to the operating table at the beginning of a case. * The Hovermat should be considered in all patients over 100kg * The Hovermat **MUST BE USED** IN ALL PATIENTS over 115kg * Refer to Policy "MANUAL HANDLING OF THE BARIATRIC PATIENT"   #### BMI and Weight Admission Matrix 1. **Weight > 130kg:** Not accepted (not negotiable). 2. **BMI 40 – 42 (Any weight):** Must meet specific clinical criteria and requires consultation with the GM/DON and Operations Director WA or National Clinical Governance Director. 3. **BMI 38 – 40 (Any weight):** Must meet specific clinical criteria and requires consultation with the GM/DON. 4. **BMI 35 – 38 (Weight < 130kg):** Must meet specific clinical criteria to be accepted. 5. **BMI ≤ 35 (Weight < 130kg):** Accepted if clinically cleared by the Anaesthetist. #### Clinical Criteria for High BMI (35-42) - ASA 1 or 2 (BMI should not be included as part of ASA criteria). - No sleep apnoea. - No respiratory disease of any significance. - No anticipated airway difficulty. - Patient is normally ambulant with minimal assistance. - Patients should be booked as morning cases or first on the afternoon list. - All patients must be reviewed by an Anaesthetist prior to surgery and approved by the DON/Clinical Nurse. - Early consultation at the Anaesthetist's rooms prior to admission is preferable. #### Manual Handling Protocols - **Patients > 90kg:** Should self-ambulate to the operating table at the beginning of a case if capable and not sedated. - **Patients > 100kg:** The Hovermat should be considered. - **Patients > 115kg:** The Hovermat must be used. - Refer to Policy: "MANUAL HANDLING OF THE BARIATRIC PATIENT" A clinical guideline table detailing patient eligibility for surgery based on weight and BMI. The table includes columns for 'Weight in KG', 'BMI Must be calculated', 'Accepted for surgery', and 'Conditions'. It categorizes patients into groups such as those over 130kg (not accepted), specific BMI ranges requiring consultation, and lower BMI categories with acceptance criteria. The final row lists detailed medical conditions like ASA status and respiratory health required for acceptance. A section titled 'Manual Handling' providing procedural instructions for managing bariatric patients. It specifies that patients over 90kg should self-ambulate if capable, the Hovermat should be considered for patients over 100kg, and MUST BE USED for patients over 115kg. It concludes by referencing a policy document. # General Anaesthetics at E Block * OHCWA use Southbank Day Surgery as their operating facility * Southbank Day Surgery has specific criteria that must be met for acceptance * Weight <130kg * BMI <40 (exceptions can be made up to 42) * No OSA * If a patient needs or requests GA and is unsuitable for Southbank, then they will be referred to colleagues within the public systems at RPH, SCGH or FSH depending on their postcode. * It is vitally important if you are referring patients to E Block, **do not promise them GA** as it can make our conversation harder and more confrontational. #### Southbank Day Surgery Criteria OHCWA utilizes Southbank Day Surgery, which maintains the following acceptance criteria: - Weight < 130kg - BMI < 40 (exceptions up to 42) - No Obstructive Sleep Apnoea (OSA) #### Referral Protocols If a patient requires or requests general anaesthesia (GA) but is unsuitable for Southbank Day Surgery, they will be referred to public system colleagues at RPH, SCGH, or FSH based on their postcode. #### Communication Guidelines When referring patients to E Block, it is vital not to promise the patient a GA. Doing so can make subsequent clinical conversations more difficult and confrontational. | How do you decide? | | :--- | | Do I have the skills to perform this? | | **Yes** | | **Can the procedure be done under local anaesthetic?** | | **Yes** | | **Is the patient happy to tolerate?** | | **Yes** | **Do under LA** | | No | **Treat as if unable to do under LA** | | No | **Can I bring in a sedationist?** | | **Yes** | **Is the patient medically suitable for this in practice, and willing to pay for the service?** | | **Yes** | **Tx under IVS** | | **No** | Either trial alternatives or consider referral | | No | **Can this be safely done with oral anxiolysis?** | | **Yes** | **Prescribe oral anxiolysis** | | **No** | **Can we consider other non pharmacological methods?** | | **Yes** | **Try this first** | | **No** | **Refer** | | No | **Refer** |  #### Procedural Decision Flow 1. **Do I have the skills to perform this?** - If No: **Refer** - If Yes: Proceed to step 2 2. **Can the procedure be done under local anaesthetic (LA)?** - If Yes: Is the patient happy to tolerate it? - If Yes: **Do under LA** - If No: Proceed to step 3 (Treat as if unable to do under LA) - If No: Proceed to step 3 3. **Can I bring in a sedationist?** - If Yes: Is the patient medically suitable for in-practice sedation and willing to pay for the service? - If Yes: **Treatment under IVS** - If No: Trial alternatives or consider referral - If No: Proceed to step 4 4. **Can this be safely done with oral anxiolysis?** - If Yes: **Prescribe oral anxiolysis** - If No: Proceed to step 5 5. **Can we consider other non-pharmacological methods?** - If Yes: **Try this first** - If No: **Refer** A flowchart titled 'How do you decide?' outlining a clinical decision-making process. The diagram begins with the question 'Do I have the skills to perform this?'. Following the 'Yes' branch, it proceeds to 'Can the procedure be done under local anaesthetic?', which splits into further decisions based on patient tolerance and suitability for IV sedation (IVS). The 'No' branch leads to referral or consideration of oral anxiolysis/non-pharmacological methods. Arrows connect all nodes, visually representing the logical progression and branching paths. [^1]: Original PDF page 1: [[L5 GA RA Anxiolysis.pdf#page=1|L5 GA RA Anxiolysis, p.1]] [^2]: Original PDF page 2: [[L5 GA RA Anxiolysis.pdf#page=2|L5 GA RA Anxiolysis, p.2]] [^3]: Original PDF page 3: [[L5 GA RA Anxiolysis.pdf#page=3|L5 GA RA Anxiolysis, p.3]] [^4]: Original PDF page 4: [[L5 GA RA Anxiolysis.pdf#page=4|L5 GA RA Anxiolysis, p.4]] [^5]: Original PDF page 5: [[L5 GA RA Anxiolysis.pdf#page=5|L5 GA RA Anxiolysis, p.5]] [^6]: Original PDF page 6: [[L5 GA RA Anxiolysis.pdf#page=6|L5 GA RA Anxiolysis, p.6]] [^7]: Original PDF page 7: [[L5 GA RA Anxiolysis.pdf#page=7|L5 GA RA Anxiolysis, p.7]] [^8]: Original PDF page 8: [[L5 GA RA Anxiolysis.pdf#page=8|L5 GA RA Anxiolysis, p.8]] [^9]: Original PDF page 9: [[L5 GA RA Anxiolysis.pdf#page=9|L5 GA RA Anxiolysis, p.9]] [^10]: Original PDF page 10: [[L5 GA RA Anxiolysis.pdf#page=10|L5 GA RA Anxiolysis, p.10]] [^11]: Original PDF page 11: [[L5 GA RA Anxiolysis.pdf#page=11|L5 GA RA Anxiolysis, p.11]] [^12]: Original PDF page 12: [[L5 GA RA Anxiolysis.pdf#page=12|L5 GA RA Anxiolysis, p.12]] [^13]: Original PDF page 13: [[L5 GA RA Anxiolysis.pdf#page=13|L5 GA RA Anxiolysis, p.13]] [^14]: Original PDF page 14: [[L5 GA RA Anxiolysis.pdf#page=14|L5 GA RA Anxiolysis, p.14]] [^15]: Original PDF page 15: [[L5 GA RA Anxiolysis.pdf#page=15|L5 GA RA Anxiolysis, p.15]] [^16]: Original PDF page 16: [[L5 GA RA Anxiolysis.pdf#page=16|L5 GA RA Anxiolysis, p.16]] [^17]: Original PDF page 17: [[L5 GA RA Anxiolysis.pdf#page=17|L5 GA RA Anxiolysis, p.17]] [^18]: Original PDF page 18: [[L5 GA RA Anxiolysis.pdf#page=18|L5 GA RA Anxiolysis, p.18]] [^19]: Original PDF page 19: [[L5 GA RA Anxiolysis.pdf#page=19|L5 GA RA Anxiolysis, p.19]] [^20]: Original PDF page 20: [[L5 GA RA Anxiolysis.pdf#page=20|L5 GA RA Anxiolysis, p.20]] [^21]: Original PDF page 21: [[L5 GA RA Anxiolysis.pdf#page=21|L5 GA RA Anxiolysis, p.21]] [^22]: Original PDF page 22: [[L5 GA RA Anxiolysis.pdf#page=22|L5 GA RA Anxiolysis, p.22]] [^23]: Original PDF page 23: [[L5 GA RA Anxiolysis.pdf#page=23|L5 GA RA Anxiolysis, p.23]] [^24]: Original PDF page 24: [[L5 GA RA Anxiolysis.pdf#page=24|L5 GA RA Anxiolysis, p.24]] [^25]: Original PDF page 25: [[L5 GA RA Anxiolysis.pdf#page=25|L5 GA RA Anxiolysis, p.25]] [^26]: Original PDF page 26: [[L5 GA RA Anxiolysis.pdf#page=26|L5 GA RA Anxiolysis, p.26]] [^27]: Original PDF page 27: [[L5 GA RA Anxiolysis.pdf#page=27|L5 GA RA Anxiolysis, p.27]] [^28]: Original PDF page 28: [[L5 GA RA Anxiolysis.pdf#page=28|L5 GA RA Anxiolysis, p.28]] [^29]: Original PDF page 29: [[L5 GA RA Anxiolysis.pdf#page=29|L5 GA RA Anxiolysis, p.29]] [^30]: Original PDF page 30: [[L5 GA RA Anxiolysis.pdf#page=30|L5 GA RA Anxiolysis, p.30]] [^31]: Original PDF page 31: [[L5 GA RA Anxiolysis.pdf#page=31|L5 GA RA Anxiolysis, p.31]] [^32]: Original PDF page 32: [[L5 GA RA Anxiolysis.pdf#page=32|L5 GA RA Anxiolysis, p.32]] [^33]: Original PDF page 33: [[L5 GA RA Anxiolysis.pdf#page=33|L5 GA RA Anxiolysis, p.33]] [^34]: Original PDF page 34: [[L5 GA RA Anxiolysis.pdf#page=34|L5 GA RA Anxiolysis, p.34]] [^35]: Original PDF page 35: [[L5 GA RA Anxiolysis.pdf#page=35|L5 GA RA Anxiolysis, p.35]] [^36]: Original PDF page 36: [[L5 GA RA Anxiolysis.pdf#page=36|L5 GA RA Anxiolysis, p.36]] [^37]: Original PDF page 37: [[L5 GA RA Anxiolysis.pdf#page=37|L5 GA RA Anxiolysis, p.37]] [^38]: Original PDF page 38: [[L5 GA RA Anxiolysis.pdf#page=38|L5 GA RA Anxiolysis, p.38]] [^39]: Original PDF page 39: [[L5 GA RA Anxiolysis.pdf#page=39|L5 GA RA Anxiolysis, p.39]] [^40]: Original PDF page 40: [[L5 GA RA Anxiolysis.pdf#page=40|L5 GA RA Anxiolysis, p.40]] [^41]: Original PDF page 41: [[L5 GA RA Anxiolysis.pdf#page=41|L5 GA RA Anxiolysis, p.41]] [^42]: Original PDF page 42: [[L5 GA RA Anxiolysis.pdf#page=42|L5 GA RA Anxiolysis, p.42]] [^43]: Original PDF page 43: [[L5 GA RA Anxiolysis.pdf#page=43|L5 GA RA Anxiolysis, p.43]] [^44]: Original PDF page 44: [[L5 GA RA Anxiolysis.pdf#page=44|L5 GA RA Anxiolysis, p.44]] [^45]: Original PDF page 45: [[L5 GA RA Anxiolysis.pdf#page=45|L5 GA RA Anxiolysis, p.45]] [^46]: Original PDF page 46: [[L5 GA RA Anxiolysis.pdf#page=46|L5 GA RA Anxiolysis, p.46]] [^47]: Original PDF page 47: [[L5 GA RA Anxiolysis.pdf#page=47|L5 GA RA Anxiolysis, p.47]] [^48]: Original PDF page 48: [[L5 GA RA Anxiolysis.pdf#page=48|L5 GA RA Anxiolysis, p.48]] [^49]: Original PDF page 49: [[L5 GA RA Anxiolysis.pdf#page=49|L5 GA RA Anxiolysis, p.49]] [^50]: Original PDF page 50: [[L5 GA RA Anxiolysis.pdf#page=50|L5 GA RA Anxiolysis, p.50]]