Advanced Education In General Dentistry

Module 01: Advanced Pain Control and Sedation

Clinical Assessment and Guidelines

Clinical Procedure

Intraprocedural Management

Intraoperative management requires well-trained personnel, monitoring equipment and emergency equipment. With conscious sedation, or moderate sedation, the sedation is directed by a qualified practitioner. A second qualified individual, competent to monitor and observe and to intervene if necessary, should also be present in the room. There should also be a third individual to assist with the procedure.


Monitoring of the patient is required. These include monitoring the patient's respiratory rate and patency of the airway. The patient's vital signs, including heart rate, blood pressure, oxygen saturation and level of consciousness must also be continuously assessed. The electrocardiogram may be required based upon the history and/or state regulation.

The first piece of equipment is a blood pressure cuff. Prior to starting any sedation, the patient's baseline blood pressure should be obtained.

The pulse oximeter is used to monitor the resting oxygen saturation in a patient's red blood cells, and will also monitor the patient's heart rate. The probe is placed on the patient's index finger, and readings are provided by the monitor. Again, a baseline measurement should be obtained prior to sedation. For more information on pulse oximetry visit

Finally, an electrocardiogram monitor, also refered to as an ECG or EKG monitor, is used to monitor the electrical activity of the patient's heart. To obtain readings, remove the protective covering from the electrodes and place one on each of the patient's arms and legs, and on his chest. Once all of the leads are in place, turn on the ECG monit continued monitoring of the patient's cardiac rhythm, displayed on the ECG monitor screen.

The JCAHO's competency course on Sedation & Analgesia provides more information on Monitoring, including heart rate, respirations, EKG, blood pressure and oxygenation at View the section on monitoring, and take the review quiz at the end to test your knowledge.

Placing an IV

Before you begin placing the IV, make sure that you have the following materials gathered and organized within reach:

  1. IV Fluid Bag
  2. IV Tubing
  3. Tourniquet
  4. Angiocatheter (Consists of a needle with an overlying catheter)
  5. Alcohol Swab
  6. Gauze
  7. Tape

Begin by connecting the IV tubing to the IV fluid bag and let the fluid run intothe tubing until all of the air is flushed from the line. Once this is done clamp the tubing to stop the fluid. At this point squeeze the IV tubing chamber so that it is half full. (The chamber is the round portion of the tubing that is adjacent to the "Tubing - Bag" connection. Doing this allows you to monitor the rate of fluid flow.)

Place the tourniquet on the patients arm, and identify a target vein. Once you see or feel a suitable vein, try to determine its direction by palpating the area. Doing this will help you approach the vein with an angiocatheter in the right direction. Finally clean the area with an alcohol swab prior to catheter insertion.

Take the angiocatheter with the bevel (the needle is cut at an oblique angle) facing away from the skin and insert into the vein at a low angle (approximately 15 degrees). Once you enter the vein blood will flow into the angiocatheter (called flashback). At this point only the needle portion of the angiocatheter is within the vein, therefore advance the angiocatheter approximately 1mm to allow the catheter portion to enter into the vessel lumen. (The needle portion is about 1mm beyond where the catheter portion starts) Now stabilize the needle and advance the catheter into the vein.

Finally remove the tourniquet, place pressure at the tip of the catheter, and while securing the catheter with your fingers take out the needle portion of the angiocatheter, leaving the catheter in place. Once the needle is removed quickly connect the IV tubing to the catheter. Now secure the catheter with tape, unclamp the IV tubing and start the fluid. IV fluid should flow easily and this will confirm that you are in the vessel lumen. If IV fluid does not flow easily you may need to reposition the catheter.

Further Reading

Medley, CC, Linman, RM and Davenport, WL. Monitoring for Oral and Maxillofacial Surgery. In: Fonseca, R, Walker, R and Betts, N, editors. Oral & Maxillofacial Surgery, Volume 1. Saunders: 2000. p. 41-57.

Emergency Equipment

Emergency equipment includes Yankowor (SP?) suction, a device to provide for bag/mask ventilation with an oxygen source, emergency medications, and emergency telephone numbers. A defibrillator and intubation equipment must also be available as required by state law.